





.0 ^ 



^ -V:-''^^'^ 



* \ • ^ » o /^ V-. . ^ ■ '^ 'I ^ V . 






■^.v. < 
■x"^ 



i.V 



^'\ 


















x^--^ 



^. . //'-^ ^ 



>*^ "- 






'^;,. ^■i- 



,>' ■'■:. 



'.'^^.- ■'^ 



%.<^ 



^?y.<f % 






^°-*.. 






r^'^ Ci- 






0- ^;;^ 


■' '. V 




N ^ ' // -^ 




.^.^rirW' 


"^ 


.^' 




-s^ 


■^>-. 




-sP^' 


'" 



■0-' 



'\ 



^ s- 












^^- . ^ 0^ 









^<'\^'^" - 



-^oV 



o 



o^ ^-<- 






f ?'^ 









0- 



.x^''%. 






^ -^^ ■>bv^ -^-0^ ^.' 



■'-t.. .V. 



„-^ °x 



^>rtr:^^v '., v-r^r^* s#' , .„.^. 



. .<=^ 






°-"c/co-.:^b'-^^^ 




^'\ '.^^' '^^ 







^o V 







^ /■■ 




■N^^'V =..¥l|w^ 



,;f^ 






-^ 



"^^ d*^' 



■ .0- 







4* % '-. 










.^ <^n 



- ^^= 



-7- 






/.^:::^^% 



^j^m^ 



V V!- ^ - " /■ O 



"b > . 









<:r. a\ - r^ 



^- -^..^^^ 






8 . -^. 




^0 






/ _.^^ 



: %4^ ^ 



.s> ^^. 



■Jj, ^ ^h^iiy^ -% 



.. ^ .^"% 



^ 


















v'-^ 



-O^^ • »., ,-^ .^0•' 






/'. 




,/.^ 










^* o.^' 






0\oO 





x^-/.. 



•" ,-^ 



^ 







'*-'"<c^. eP"^ .-"::-«.'^ 



0- O, '' 

o N fv^ ' ; 







•f/- V 
A qX 



o-^ ^X 


























V , . . 



A.. 



8 * "<- 












A ^x 






«„ ^/._ " « '^ ^f 



aO- 



THE PRACTICE OF 
OSTEOPATHY 




» 



CARL PHILIP McCONNELL 

President American Osteopathic Association, 1904-05. Formerly of the 

Faculty American School of Osteopathy. Member of the Faculty 

Chicago College of Osteopathy 



CHARLES CLAYTON TEALL 

President American Osteopathic Association, 1902-03. Dean of the Faculty 

and Professor of Practice and Clinical Osteopathy American School 

of Osteopathy. Editor Journal of Osteopathy 



FOURTH EDITION 

Rewritten in collaboration with osteopathic specialists of note 
with much new and original matter 



1920 

JOURNAL PRINTING CO. 

Ktrksville, Mo. 



1 7^ 



Copyright 1920 
Carl Philip McConnell and Charles Clayton Teall 



©CI.A571438 



Dedicated 
To THE Memory 

OF 

Andrew Taylor Still 



First Edition 1S99 
Second Edition 1902 
Third Edition 1906 
Fourth Edition 1920 



PREFACE TO THE FOURTH EDITION 

A science is said to be known by its literature and, if that be true, 
Osteopathy is backward for there are few available books on the subject 
for the student and investigator although there is a vast amount of un- 
classified journalistic matter. A pretentious start was made and, for 
a time, it appeared that we should have texts on all subjects for the 
teaching of Osteopathy but, for reasons not necessary to give here, these 
books did not Hve although their value and need was never questioned. 

The third edition of the Practice of Osteopathy was exhausted very 
soon after publication and there have been insistent calls for a fourth 
which is now presented with the hope that it will find as friendly a re- 
ception as was accorded the previous editions. Close attention to cur- 
rent literature has been given and reports from experienced practitioners 
in the field has been sought and this material made use of wherever pos- 
sible. Besides this, certain sections have been written by speciahsts in 
their several fines whose signed articles we confidently present. The 
subject of osteopathic practice has been handled to avoid undue optimism 
in the light of experience but, also, not to lose sight of the fact that os- 
teopathy won its way by performing the so-called impossible in a multi- 
tude of cases. Therefore, it has been thought best not to draw a hard 
and fast line on our limitations. 

The border line between osteopathy and surgery has been demon- 
strated as well as can be done on paper without the actual patient in 
hand. Medical literature has been called upon to give its store of know- 
ledge wherever our needs have appeared and all osteopathic prints have, 
also, given from their accumulated wisdom and experience. 

The authors acknowledge, with thanks, this information from the 
many writers for osteopathic journals who have created a great fund of 
knowledge on osteopathic subjects and particularly those who have con- 
tributed special sections. 

Carl Philip McConnell. 
1920. Charles Clayton Teall. 



" /J^STEOPATHY is not so much a question of 
^^*^ books as it is of intelligence. A successful 
osteopath is in all cases, or should be, a person of indi- 
viduahty with a mechanical eye behind all motions or 
efforts to readjust any part of the body to its original 
normahty, because unguided force is dangerous, often 
doing harm and faihng to give relief that should be the 
reward of well directed skill. " — A. T. Still 



LIST OF CONTRIBUTORS 

Raymond W. Bailey, D. O. 

Former member of the faculty, Philadelphia College of Osteopathy. 
{Defective Children) 

Edgar S. Comstock, D. 0. 

Professor of Principles of Osteopathy, and of Respiratory and In- 
fectious Diseases, Chicago College of Osteopathy. 
{Infectious Diseases) 

J. Deason, M.S., Ph. G., D. O. 

Professor of Rhinology, Laryngology and Otology, Chicago College 
of Osteopathy. 

{Ear^ Nose and Throat) 

L. VAN Horn Gerdine, A. M., M. D., D. O. ' 

Neurologist, Still-Hildreth Sanatorium. 

{Mental Diseases) 

A. G. HiLDRETH, D. 0. 

Superintendent, Still-Hildreth Sanatorium. 
{Mental Diseases) 

H. S. Hain, D. 0. 

Professor of Orthopedics, American School of Osteopathy, Ortho- 
pedic Surgeon, A. S. 0. Hospitals. 

{Deformities) 

Earl R. Hoskins, Sc. B., D. 0. 

Professor of Clinical Osteopathy, X-Radiance and Diagnosis, Chi- 
cago College of Osteopathy. 
{Diseases of the Blood) 

Charles J. Muttart, D. 0. 

Professor of Diagnosis and Technique and of Gastroenterology, 
Philadelphia College of Osteopathy. 
{Diseases of the Stomach) 

George M. McCole, D. 0. 

Osteopathic Practitioner and Writer. 
{Influenza) 
Charles C. Reid, M. D., D. O. 

President, Denver Polyclinic and Post-Graduate College. 
( Ophthalmology) 
George A. Still, M. S., M. D., D. 0. 

Professor of Surgery, American School of Osteopathy, Surgeon in 
Chief, A. S. 0. Hospitals. 

{Post- Operative Treatment) 



TABLE OF CONTENTS 

PART I. 

Introduction 17 

Osteopathic Etiology and Pathology 24 

Osteopathic lesion; Etiological factors; Osseous lesion; Muscular lesion; Liga- 
mentous lesion; Visceral lesion; Composite lesion; Pathology; Spinal lesions; 
Proof. 

Osteopathic Diagnosis and Prognosis 38 

The Spine; Examination; Vertebrae; Position in examination; Neck, Head 
and Face, Atlas, Axis, Skull, Third Cervical, Muscles of the Neck, Temporo- 
Maxillary Articulation, Scalp, Ribs, Clavicle, Sternum, Dorso-Lumbar, 
Thorax, Abdomen, Gall Bladder, Spleen, Stomach, Intestines, Kidneys, 
Lumbar, Pelvis, Coccjrx, Arms, Legs. 

Osteopathic Prognosis 56 

Osteopathic Technique 60 

Sense of touch, Definite principles. General treatment, Position, Neck, Head, 
Ribs, Dorsal, Lumbar, Abdomen, Pelvis, Legs, Arms, How often to treat. 
Length of treatment, Over treatment, Misapplied treatment. 
Osteopathic Centers, Stimulation, Inhibition, Readjustment, Vasomotor 

AND Sensory Nerves 88 

Spinal Curvature 96 

Pott's Disease 102 

Sprains 104 

Flat Foot 112 

Fractures 115 

Postural Defects 120 

Round Shoulders, Painful Shoulders, Pendulous Abdomen, Postural Curvature 
of the Spinal Column. 

Prolapsed Organs 133 

Prolapsed and Dilated Stomach, Prolapsed Kidney, Liver Prolapse, Pro- 
lapsed Intestines, Prolapsed Uterus, Ovarian Displacements. 

Skin Diseases 147 

Eczema, Herpes Simplex, Herpes Zoster, Urticaria, Acne. 

Animal Parasites 151 

Tape Worm, Round Worm, Pin Worm, Hook Worm, Trichiniasis, Filiaria. 

Hemorrhages 160 

Epistaxis, Hemoptysis, Hematemesis, Intestinal Hemorrhage, Hematuria, 
L^terine Hemorrhage. 

Hiccoughs 165 

Varicose Veins 166 

Phlebitis 168 

The Rectum 169 

Local Treatment, Proctitis, Hemorrhoids, Rectal Conditions. 

Genito-Urinary 175 

Prostate Gland, Acute Prostatitis, Chronic Prostatitis, Seminal Vesicles, 
Varicocele, Impotency. 



10 The Practice of Osteopathy 

Heat Stroke 180 

Department of Ophthalmology 183 

Examination of the Eye, Ciliospinal Center, Somatic Reflexes, Accommoda- 
tion in the Eye, The Ophthalmoscope, Diseases of the Eye, Neuralgia, Dis- 
eases of the Eyelids, Lachrymal Apparatus, Conjunctiva, Ophthalmia Neona- 
torum, Trachoma, Phlyctenular Conjunctivitis, Vernal Conjunctivitis, Dis- 
eases of the Cornea, Examination, Ulcer, Xerosis, Keratitis Neuropatalytica, 
Pannus, Phlyctenular Keratitis, Interstitial Keratitis, Diseases of the Iris and 
Ciliary Body, Diseases of the Choroid, Glaucoma, Diseases of the Lens, Cata- 
ract, Diseases of the Retina, Optic Neuritis, Optic Atrophy, Asthenopia. 

Diseases of the Ear, Nose and Throat 236 

Examination, Diseases of the Auditory Meatus, Diseases of the Middle Ear, 
Acute Mastoiditis, Chronic Mastoiditis, Otitis Media, Catarrhal Deafness, 
Normal Hearing, Diseases of the Middle Ear, Diseases of the Nose, Rhinitis, 
Hay Fever, Sinuitis, Epistaxis, Diseases of the Nasopharynx, Adenoids, Dis- 
eases of the Oropharynx, Tonsillitis, Tonsillectomy, Quinsy. 

Mental Diseases 282 

Dementia Praecox, Delirium, Confusion and Stupor, Manic Depressive 
Psychosis, Involutional Psychosis, Senile Dementia. 

Defective Children 303 

Tendencies, Amentia, Treatment. 

Post-operative Treatment 312 

Vomiting, Backache and Headache, Neuritis, Phlebitis, Nephritis, Pleurisy, 
Pneumonia. 

PART II. 

Infectious Diseases 

Fever 325 

Typhoid Fever 329 

Typhus Fever 344 

Malarial Fever 347 

Septicemia 355 

Pyemia 356 

Dengue 356 

Cerebrospinal Meningitis 358 

Diphtheria 362 

Dysentery 368 

Acute Iliocolitis 368 

Amebic Dysentery 370 

Chronic Dysentery 371 

Erysipelas 372 

Yellow Fever 374 

Tetanus ,. 377 

Simple Continued Fever 379 

Tuberculosis 380 

Influenza 399 

Acute Eruptive Fevers 412 

Smallpox 413 

Varioloid 420 



The Practice of Osteopathy 11 

Vaccination 424 

Scarlet Fever 42S 

Measles 437 

Rubella 444 

Varicella 446 

Mumps . . .449 

Whooping Cough 452 

Constitutional Diseases 

Rheumatic Fever 457 

Chronic Articular Rheumatism 460 

Arthritis Deformans 462 

Muscular Rheumatism 465 

Gout 467 

Diabetes Mellitus : 470 

Diabetes Insipidus 476 

Rickets 478 

Obesity .' 480 

Scurvy 481 

Infantile Scurvy - 482 

Purpura 483 

Hemophilia 484 

Diseases op the Digestive System 

Stomatitis 487 

Catarrhal Stomatitis 487 

Appthous Stomatitis 488 

Ulcerative Stomatitis 488 

Parasitic Stomatitis 489 

Diseases of the Gastrointestinal Tract 

Applied Anatomy 490 

Acute Gastritis 502 

Chronic Gastritis 505 

Gastric Neuroses 510 

Gastric and Duodenal Ulcer 513 

Dilatation of the Stomach 517 

Gastroptosis and Enteroptosis ' 521 

Diseases of the Intestines 

Acute Diarrhea 523 

Chronic Diarrhea and Mucous Colitis 526 

Diarrhea in Children 529 

Acute Dyspeptic Diarrhea 529 

Cholera Infantum 531 

Acute Enterocolitis 532 

Cholera Morbus ■. 533 

Intestinal Colic 535 

Constipation 537 

Intestinal Obstruction 541 

Hernia 547 

Appendicitis 547 



12 The Practice of Osteopathy 

Diseases of the Liver and Bile Duct 

Hyperemia of the Liver - 554 

Simple Catarrhal Jaundice 555 



Cholecystitis . 



557 



Jaundice 55S 

Cirrhosis of the Liver 560 

Fatty Liver 562 

Amyloid Liver 562 

Gall Stones 563 

Diseases of the Spleen 

Splenitis ^^" 

Diseases of the Respiratory Tract 

Acute Laryngitis 569 

Chronic Catarrhal Laryngitis 570 

Laryngismus Stridulus 572 

Spasmodic Laryngitis 573 

Tuberculous Laryngitis 575 

Syphilitic Laryngitis • • • • • 5 ' ^ 

Edematous Laryngitis 577 

Diseases of the Bronchi 

Acute Bronchitis 579 

Chronic Bronchitis 582 

Fibrinous Bronchitis 585 

Bronchiectasis ^°' 

Bronchial Asthma 589 

Diseases of the Lungs 

Emphysema '^^ 

Acute Lobar Pneumonia 59/ 

Bronchopneumonia "^5 

Chronic Interstitial Pneumonia 609 

Congestion of the Lungs ^^^ 

Edema of the Lungs ^^^ 

Diseases of the Pleura 

Pleurisy •• *J1^ 

Acute Pleurisy 

Serofibrinous Pleurisy "^^ 

Chronic Pleurisy ^^^ 

Diseases of the Urinary System 
Diseases of the Kidneys 

Renal Hyperemia "^ ' 

Acute Parenchymatous Nephritis ^1^ 

Chronic Parenchymatous Nephritis 621 

624 



Interstitial Nephritis 

Amyloid Kidney 626 

Pyelitis 627 

Uremia ^^^ 

Renal Calculus 631 



The Practice of Osteopathy 13 

Diseases of the Bladder 

Cystitis 635 

Diseases of the Circulatory System 
Diseases of the Pericardium 

Pericarditis 638 

Endocarditis 641 

Chronic Endocarditis 645 

Hypertroph}^ of the Heart ,. . 655 

Dilatation of the Heart 657 

Myocarditis 659 

Degeneration of the Heart Muscle 661 

Neuroses of the Heart , 662 

Angina Pectoris 666 

Diseases of the Arteries 

Arteriosclerosis - 669 

Diseases of the Blood 

General Consideration '. . . 671 

The Anemias 672 

Costogenic Anemia , 674 

Chlorosis 676 

Pernicious Anemia 678 

The Leucemias 680 

SplenomeduUary Leucemia 681 

Lymphatic Leucemia 682 

Hodgkin's Disease 684 

Diseases of the Thyroid Gland 

Congestion 686 

Inflammation of the Thyroid 686 

Simple Goiter 687 

Exophthalmic Goiter 690 

Myxedema ■ 697 

Cretinism 698 

Diseases of the Parathyroid Gland 

Tetany 699 

Diseases of the Thymus 702 

Diseases of the Adrenal Glands 703 

Addison's Disease 704 

Diseases of the Nervous System 
Diseases of the Nerves 

Neuritis 706 

Neuralgia 710 

Diseases of the Cranial Nerves 

Olfactory 715 

Optic 715 

Motor Oculi 716 

Patheticus 716 

Trigeminus 717 

Facial 717 



14 The Practice of Osteopathy 

Auditory 718 

Glosso-PharjTigeal 718 

Pneumogastric 718 

Spinal Accessory 719 

Hypoglossal 719 

Diseases of the Spinal Nerves 

Cervical Nerves 719 

• Phrenic Nerve 720 

Brachial Plexus ' 721 

Dorsal Nerves 721 

Lumbar Nerves 722 

Sacral Nerves 722 

General and Functional Diseases 

Paralysis Agitans 723 

Acute Chorea 725 

Choreiform Affections 727 

Infantile Convulsions 728 

Epilepsy 729 

Migraine 736 

Occupation Neurosis 738 

Hysteria 740 

Neurasthenia 744 

Diseases of the Spinal Cord 

Acute Myelitis 748 

Poliomyelitis 750 

Acute Ascending Paralysis 753 

Locomotor Ataxia 754 

Friedreich's Ataxia 759 

Spastic Paraplegia 760 

Ataxic Paraplegia 761 

Syringomyelia 761 

Atrophic Lateral Sclerosis , 763 

Progressive M uscular Atrophy 764 

Bulbar Paralysis 765 

Orthopedic Surgery 

Scoliosis 767 

Functional Curvature 773 

Organic Curvature 774 

Congenital Dislocation of the Hip 778 

Talipes 784 

Pott's Disease 788 

Hip-Joint Disease 791 

Tuberculosis of the Knee-Joint 793 

The Plaster Cast Bandage 795 

Index 797 



PART FIRST 



The Practice of Osteopathy 1? 



INTRODUCTION 

What Hippocrates was to the Allopath, what Hahnemann was to 
the Homeopath, Andrew Taylor Still is to the Osteopath, and it is safe 
to say that when another century shall have rolled away, his fame will 
be equal to that of either. -^ That he is. a maker of history, even the most 
skeptical will admit. His teachings are revolutionary but are borne out 
in fact, and on that as a foundation, is built the superstructure of the 
young therapeutic giant — Osteopathy. 

It would be of great interest to trace the history of the first incep- 
tion of the thought that drugs were not only unnecessary but harmful, 
then view the struggle to grasp something tangible to take their place, 
then see the development of the idea that the human body has within it 
all that is needed for its upbuilding and repair until he came to this fun- 
damental: "The power of the artery must be absolute, universal and 
unobstructed or disease will result. The moment of its disturbance 
means the period when disease begins to sow the seeds of destruction in 
the human body; and in no case can it be done without a broken or sus- 
pended current of arterial blood," capped by the epoch-making discov- 
ery of the cause for this interrupted flow of the blood stream — the theory 
of obstruction by anatomical displacement. It is the only theory of 
the etiology of disease that will stand the test of science and its accept- 
ance and practice means a revolution in the field of therapeutics. 

^ As it is, he sets the exact date, June 22, 1874, when the hght dawned 
and he saw the outline of his great philosophy — Osteopathy. Then 
came the years of adversity and struggle. With the eye of a prophet 
he saw the future of that philosophy, and with the firmness of a Spartan 
has defended it since birth. It must be. a separate, distinct system. Out- 
side the fact that it was to heal the sick and was founded on a knowledge 
of anatomy and physiology it had nothing in common with existing 
schools, and if it were ever to grow it must be alone, for his brother prac- 
titioners would have none of it and if left to their tender mercies it would 
have "died a-borning. " Even had it been taken up the result would 
have been the same for they would never have fully developed it. And 
so through the lean, terrible years he struggled, buoyed by the faith of 
a discoverer, urged on by love of this child of his brain, fanatical in his 
determination to win. And win he did for it was vouchsafed to him in his 
vigorous old age to sit on his hearthstone and see the results of his work, 
his struggle and his faith. It is something to know that his fame has 



18 The Practice of Osteopathy 

circled the earth, to be honored and sung by miUions; a boon not accorded 
many a sage or philosopher. Not only has the pubhc accepted it but the 
medical profession is making tardy but forced recognition of certain car- 
dinal principles of osteopathy by using them, but, of course, without credit. 

Osteopathy has been defined as "that science or system of heahng 
which emphasizes, (a) the diagnosis of disease by physical methods with 
the view of discovering, not the symptoms but the cause of disease in 
■connection with misplacements of tissue, obstruction of the fluids and 
interference with the forces of the organism; (b) the treatment of dis- 
ease by scientific manipulations in connection with which the operating 
physician mechanically uses and apphes the inherent resources of the 
organism to overcome disease and estabhsh health, either by removing 
or correcting mechanical disorders and thus permitting nature to recup- 
erate the diseased parts, or by producing and estabhshing anti-toxic and 
anti-septic conditions to counteract toxic and septic conditions of the 
organism or its parts; (c) the apphcation of mechanical and operative 
surgery in setting fractures or dislocated bones, repairing lacerations 
.and removing abnormal tissue growths or tissue elements when these 
become dangerous to organic life. "^ In a word, osteopathy is adjust- 
ment and the osteopath is an anatomical engineer who knows what is 
wrong and has the abihty to correct it. Dr. Still changed diagnosis 
from guess work to fact and on it his fame may well stand, for when the 
•cause of the disease was found, treatment was easy. He has ever em- 
phasized the necessity of thorough examination and correct diagnosis. 
All treatment must be based on the definite, specific object to accomplish 
certain definite, specific things. 

"Osteopathy would expound and apply the true philosophy of 
manipulation. While the hands are used, it is not this alone and chiefly 
that distinguishes its method of operation, but the idea and purpose that 
lie behind manipulation. "^ 

All manipulators are not osteopaths any more than all butchers are 
surgeons. The need for deep study of the subject is apparent from this 
characteristic statement of Dr. Still's: "Osteopathy is a science; not 
what we know of it, but the subject we are working is deep as eternity. 
We know but little of it. I have worked and worried here in Kirksville 
for twenty-two long years, and I intend to study for twenty-three thous- 
and years yet. "'^ This brings us to the point of the relations of oste- 

1. Littlejohn, (J. M.) — Journal of the Science of Osteopathy. 

2. Encyclopedia Americana. 

3. Booth — History of Osteopathy. 



The Practice of Osteopathy 19 

opathy with other manipulative forms of treatment. They are not 
many, for Gerdine/ in closing a long article on the "Physiological Effects 
of Mechanical Therapeutics" says: "I have striven to show that in 
no way is Osteopathy similar to massage either in theory or practice 
if Osteopathy is conceived of, according to its founder, Dr. A. T. Still, 
as a system of healing in which a definite lesion in form of a bony dis- 
placement is the causative factor and a removal of the same, the cura- 
tive factor in disease. " 

The fact that use is made of the hands to the extent it is by both 
osteopaths and masseurs or Swedish movement operators gives rise to 
the mistaken idea of similarity in treatment. 

"The essential distinction," says G. D. Hulett, "between Oste- 
opathy and all other systems of heaHng based on manipulation, clusters 
around the etiology of disease. While these other systems, as indicated 
at least by their practice, look at disease from a peripheral standpoint, 
osteopathy views it from a central standpoint."" 

Massage is a small branch of manipulative therapeutics, but con- 
ceding that it is perfect and scientific it can only resemble' osteopathic 
treatment in one ramification of osteopathic practice, viz: relaxation 
of muscles. 

The fact that massage is often employed by osteopaths in connec- 
tion with their work shows the limitations of that form of treatment. 
Says McConnell^: "In the human body, as in any delicate, comph- 
cated mechanism, there is mechanism within mechanism; and, in order 
to obtain certain mechanical effects, many times there is required a series 
of compHcated movements, all of which bear a ratio one to the other 
according to the energy utiHzed and the mechanical principle involved. " 
No other form of manual treatment takes this principle of mechanics 
into consideration. It is possible, as Gerdine points out, for an unde- 
veloped osteopath to practice massage under another name. That the 
two should be confounded before the public is due to his ignorance and 
not from any fault of the system. Massage is a valuable aid in the 
treatment of disease but it is not Osteopathy. 

"In the bright lexicon of osteopathy there is no such word as rub^. " 

Osteopathy in its relation with medicine has httle in common. From 
the beginning, its founder reahzed their paths should run divergently, 

1. Journal of Osteopathy, May, 1905. 

2. Principles of Osteopathy, p. 190. 

3. Journal of the Science of Osteopathy, Doc. 1.5, 1900. 

4. Osteopathic Calendar, 1900. 



20 The Practice of Osteopathy 

so the first step, its teaching, must be considered from a different view- 
point. To quote from an address by Teall^: "But to adequately teach 
osteopathy a vast amount of original work must be done. Anatomy is 
anatomy but there is a vast difference in its apphcation. Physiology 
must be taught to mean something more than an interesting phenomenon. 
Pathology has an unfilled gap between cause and effect which must be 
bridged. The post-mortem has a great story to tell but an osteopath 
must tell it. A slide of degenerated tissue under the microscope is of 
interest, but why the degeneration? It is described at length by the 
authorities, but the reason for the causes and morbific changes are not 
carried out. Obstetrics along strictly natural and physiological Unes 
insuring both mother and babe against injury; gynecology, minus the 
knife and plus common sense; all these, and more must be put into shape 
to teach the osteopathic student. The archives of osteopathy were 
empty ten years ago. There was no precedent to follow and the ideas 
in teaching which had prevailed for centuries dominated. All this is 
changed. The colleges teach the science along strictly osteopathic lines, 
making the apphcation of the truths which have escaped the notice of 
centuries of investigation." 

All schools recognize the wonderful recuperative power of nature, 
as this from the introduction of a standard allopathic text book will 
show^: "There is no scientific dogma better established than this: 
that the Uving organism is in itself adequate to the cure of all its cur- 
able disorders. This natural law sustains the medical skeptic in his 
infidehty, enables the homeopath to report his sugar cures, and helps 
all physicians out of more close places than they are generally willing to 
acknowledge." But at times, as all will agree, nature is not able to 
overcome its maladies and assistance is needed. Here, again, is a di- 
vergence as to the method and character of that assistance. There is 
no system so trivial or absurd which cannot point to its cures, but a 
school of medicine should have a settled system with estabhshed methods 
of procedure. This is not true of any school employing drugs as its 
principal therapy. In the President's annual address at Cleveland he 
says^: "The observant reader of the progressive medical press is struck 
at once by the unsettled condition in the field of modern therapeutics. 
The trend is emphatically away from drugs. But, in the effort to get 
away from medicine, the medical investigator has wandered far afield, 

1. Reported, Portland, (Me.), Advertiser, Feb. 27, 1905. 

2. Potter's Materia Medica. 

3. Teall— Journal of the American Osteopathic Association, Aug., 1903. 



The Practice of Osteopathy ^ 21 

cutting loose from nature and resorting to the artificial. " It is the last 
paragraph of the extract quoted which particularly emphasizes the 
point of divergence, natural versus unnatural methods. It must be 
understood at once that the osteopath admits the reahty of drug action 
for "there is no doubt that the pharmacopeia records many drugs whose 
action is rapid and effective so far as securing activity or decrease of 
secretion is concerned, but the element of danger, i. e., their destructive 
power is great. Oftentimes their power does not stop at the point de- 
sired or Hmit its effect to the therapeutic action sought \ " This point 
of unreliabiHty of the drug is emphasized by the following from recog- 
nized medical authority^: "We give drugs for two purposes: (1) To 
restore health directly by removing the sum of the conditions which con- 
stitute disease. Here we act empirically with no definite knowledge — 
often indeed with Httle idea of the action of our drugs, but on the ground 
that in our hands or in the hands of others they have restored health 
in Hke cases. (2) To influence one or more of the several tissues and 
organs which are in an abnormal state so as to restore them to or toward 
the normal; with the hope that if we succeed in our purpose recovery 
will take place. The purpose we effect by means of the influence which 
the chemical properties or drugs exert on the structure and function of 
the several tissues and organs. Minute information, therefore, of the 
nature of drugs and their action is essential for their proper employment. " 
Osteopathy brings into action the latent or stagnant forces of nature by 
speciflc methods which are usually rehable. Naturally there being such 
a wide difference in theory of the cause of disease it would be also shown 
in diagnosis as well as treatment. The most striking points to the lay- 
man in medical procedure are: first, wide difference in the system of 
diagnosis and in its findings by physicians of the same school; second, 
the great variance in remedies employed by different physicians of the 
same school for the same disease. 

Osteopathic diagnosis is so physical in its character, depending 
upon actual conditions found and not upon the subjective symptoms 
alone, that the same patient examined by a number of experienced os- 
teopaths will be given the same diagnosis, and he will also be able to 
detect in each the same effort to correct in all their technique. All the 
methods of physical diagnosis are used plus the distinctive osteopathic 
procedure. Results wherever used bear out the effectiveness of the 
system. 

1. Tasker — Principles of Osteopathy, p. 110. 

2. Allbutt's System of Medicine. 



22 The Pkactice of Osteopathy 

The osteopath must and does consider the necessity of surgery, but 
his effort is always to prevent the operation if possible. There can be 
no doubt that surgery is carried to extremes and there is a strong senti- 
ment growing that much of it is unnecessary. Says Homer Wakefield, 
M. D.^: "It is to the everlasting disgrace and mortification of the med- 
ical man that the wealthy classes who are continually under the observa- 
tion and direction of eminent men, in dietary, and all life habits, in health 
as well as in sickness, are not only the very ones who develop appendicitis 
and most largely go to operation, but are almost exclusively those who 
attain to this distinction." The operations of to-day are wonderful and 
the surgeon shows great skill and genius in their performance, but great 
as he is in these matters how infinitely greater is the man who can pre- 
vent them. The need of the osteopath to-day is to be trained to recog- 
nize surgical conditions and neither allow surgery unnecessarily nor make 
the more terrible error of not acting soon enough. Where surgery is a 
necessity there is always an etiological factor to be considered. The 
cause of the manifestation not always being removed what is to prevent 
a recurrence or serious sequela in spite of the operation? "The special- 
ist if he has wit enough to read the lesson presented to him, that 

it is not suflficient to remove an ovarian tumor, e. g., and that if nothing 
is said at the same time or subsequently as to the causes which induced 
it, a positive damage may be done to the woman, who may, therefore, 
while considering herself cured, proceed to manufacture one on the other 
side, or may find herself in a few years suffering from cancer in the stump 
of the previous one"." And so the combination of osteopathy with 
surgery may be necessary that the cause shall be removed. Osteopathic 
treatment before operations in reducing congestions and inflammations, 
also in toning the nervous system, is particularly efficacious while the 
after treatment gives gratifying results. In fact, the two go hand in 
hand when conservatism rules both. 

That diet should receive particular attention from the osteopath is 
not strange, for his veneration of nature peculiarly fits him to realize 
the necessity of correct feeding. Probably no subject is more discussed 
or presents a wider range of opinion than diet. There is overfeeding 
and underfeeding; long intervals and short between feedings. There is 
the no breakfast and no supper plan, mixed diet and the vegetarian, un- 
cooked foods, and one exclusively of milk, anj^hing you want so long as 
you are hungry but chew it well, etc., ad. lib. All are represented by 

1. Cyclopocdia of Practical Medicine, June, 1906. 

2. Rabagliati — Air, Food and Exercise, p. 129. 



The Practice of Osteopathy 23 

osteopaths in their following as they are from other professions, but 
probably this would more nearly represent the views of them as a school : 
In health, first, most people eat too much and do not thoroughly masti- 
cate and insalivate. This applies to all stations of society. Second, 
meat forms too large an item in the daily dietary. Third, there is not 
enough variety and the ration is not well balanced as to elements. Fourth, 
not enough care is used in preparation of foods. In illness, first, the 
stopping, complete or partial, of food until the system can take care of 
it; second, the giving of easily digested foods. The man who avoids 
violent extremes in diet as well as in other habits of life will usually last 
longest. It is to be hoped that some rational system can be evolved 
on which all factions may agree, for the present confusion of authorities 
is bewildering. The osteopath gives attention to hygiene, sanitation, 
exercise, environment, mental attitude, etc., as they may affect the wel- 
fare of his patient. 

Osteopathy can cure all curable diseases, for the same forces which 
will overcome one malady will overcome another when set in motion. 
Forces that produce a diseased condition will if normahzed restore the 
estabhshed type. 



24 The Practice of Osteopathy 

OSTEOPATHIC ETIOLOGY AND PATHOLOGY 
Osteopathic Etiology 

Osteopathic etiology and pathology constitutes the most interesting 
chapter of osteopathic science. The primal divergence of the osteopathic 
schools from previous systems is to be found in the -osteopathic interpre- 
tation of disease causes and processes, and not in osteopathic therapy as 
some may think. Osteopathy makes claim to an independent school 
because it possesses a distinct etiology, pathology, diagnosis and treat- 
ment. Thus osteopathic practice is not a mere method, but instead a 
system, a school, a science. 

At no period of medical history have physicians of the older schools 
felt more keenly the futility of medical methods and the lack of an all- 
embracing principle of medicine than at the present. A recent writer^ 
who claims to have discovered a principle that encompasses the entire 
field of medicine, says: "We found, we may say, that the backbone of 
medicine was the absent factor, and that if the patient labors of so many 
great minds had not proven as useful in the development of practical 
medicine as they should, it was because they lacked such a fundamental 
framework to afford a fixed 7iidu8 for each discovery, wherein its true 
relation to other discoveries would at once become evident." 

Since the conception of osteopathy its fundamental framework has 
not changed one iota as to principle, although the application of the 
principle has been greatly elaborated. When Dr. Still proclaimed that 
"the rule of the artery is supreme" he gave utterance to a basic physio- 
logical truth. But when he demonstrated that osseous and other anata- 
mo-mechanical lesions disturbed the arter}^ and caused disease, and 
that readjustment of the anatomical cured the disorder, thus allowing 
the physiological to potentiate and revealing that the living body con- 
tains all the attributes of a vital and physical mechanism, did his teach- 
ing contain the germ of a comprehensive philosophy; this gave osteopathic 
science a "backbone" with a consequent fixed nidus for all existing facts 
and future discoveries. And thus, it should always be emphasized that 
mechanical readjustment of the component parts of the vital body is 
the eternal kej^note of the osteopathic school of healing. 

The Osteopathic Lesion. — Broadly speaking a lesion is "any 
morbid alteration in a tissue whether attended by a recognizable struc- 
tural change or not; but especially a change in which the continuity of 
1. Sajous — The Internal Secretions and the Principles of Medicine. 



The Practice of Osteopathy 25 

some of the tissue elements is broken in upon/" There are sevefal 
kinds of lesions expressing the tissue involved, character of degeneration, 
locality of same, etc. But upon analyzing the medley of arbitrarily de- 
fined lesions the fact will be evident that much of medical etiology and 
pathology has not been logically and consistently sifted and arranged; 
and moreover, it will be found the cause of causes of many diseases is 
unknown. 

Herein, arises the great significance of the osteopathic lesion, for 
the lesion alters the very governing and controlhng tissues of the body, 
viz., the nervous tissue and the vascular channels. Hulett^ defined the 
osteopathic lesion as "any structural perversion which by pressure pro- 
duces or maintains functional disorder." The constant maintenance 
of the structural perversion will, also, cause organic disease, although 
it is granted that functional disorder must necessarily result prior to 
any organic change. 

The osteopathic conception of a lesion, functional and organic dis- 
order caused by pressure from disturbed structures, does not bring us 
into an absolute new field. Medical Hterature of all ages contains refer- 
ences to diseases caused by pressure of tissues on nerves, blood vessels, 
or other channels. But the osteopathic idea is an absolutely new one 
in the appHcation of this principle universally. It simplifies and makes 
uniform the arbitrariness of present semeiology. 

Thus the osteopathic idea that many diseases originate, primarily, 
from anatomically mal-aligned, mal-positioned, or mal-related tissues 
causing a blockage of vital processes, immediate or remote, is a theory 
inclusive of disturbances to all tissues. This principle is fundamental 
and is supported by the physiological truth that uninterrupted vital 
channels preserve health; moreover chnical and experimental data, 
as will be shown later, substantiate this fundamental. It at once places 
interpretation of a lesion in an entirely new light from preconceived con- 
cepts, and is analagous to and co-extensive with etiology and pathology. 

Etiological Factors. — The osteopath believes in the potency of 
inherited and environmental influences. There can be no question that 
a few diseases and certain disease tendencies may be inherited, the prin- 
ciple feature, however, from the standpoint of heredity is, various or- 
gans and tissues have less vital resistance. These should not be con- 
founded with congenital weaknesses and diathetic tendencies. 

Environmental influences are very important factors. One's sur- 

1. Foster— Medical Dictionary. 

2. Hulett — Principles of Osteopathy. 



26 The Practice of Osteopathy 

roundings and daily habits in the home, shop, or office count for much 
in the aggregate. Food, drink, air, rest, sleep, clothing, exercise, mental 
attitude, etc., are all factors in the sum total of health, and consequently 
ill-health may be traceable to their abuse. In fact, all hygienic and 
sanitary measures are duly considered by the osteopath. Various abuses, 
over use, and disuse of the functions will certainly be followed by physio- 
logical discord. 

The germ theory contains much truth, but in the very large per- 
centage of cases where the micro-organism is a factor its significance is 
only of secondary consideration. Immunity and resistance comprise 
an important part of the health problem, of which the intact anatomical 
is of first consideration. Usually the micro-organism plays the role of 
an exciting and determining factor; before it can multiply and grow 
there must be a field that is first nutritionally disturbed. Nutrition of 
the tissue is the one great point always to be considered. The constitu- 
tion of an individual is the pivot about which predisposing, environ- 
mental, and exciting factors of disease center. Health represents the 
integrity of the artery as well as a maintenance of that master tissue, 
the nervous system, and anything that prodtices or influences, directly 
or indirectly, a disturbance of physiological functioning borders on the 
pathological. 

Hence the osteopath recognizes many of the common medical causes 
of disease, but reserves the privilege of rearranging their relative posi- 
tions, for the osteopathic cause of disease greatly modifies their value. 

Osteopathic Etiology distinctively emphasizes structural derange- 
ments, and perversions Of first importance, owing to static require- 
ments, is the osseous lesion. This lesion is represented by any abnor- 
mal change of position or relation of the many bony constituents of the 
body. The framework of the body is subject to not only any and 
every physical violence of any mechanism, but moreover being the cor- 
poreal foundation of a vital mechanism is subject to both direct and 
indirect biochemic changes and influences. 

Thus the osseous lesion is caused (a) by traumatism, e. g., strains, 
falls, blows, etc. ; (b) indirectly by atmospheric changes, over and violent 
exercise, the slumped posture, debilitating habits, etc., through the 
media of muscle changes and imbalance; (c) by nutritional effects dis- 
turbing the elements of bony tissue; (d) by ligamentous change such as 
thickening of a capsular ligament; (e) by infections; (f) compensatorily 
and reflexly through the media of body distortions and muscular irri- 
tabihty or debihty, e. g., an innominate lesion may be compensatory to 



The Practice of Osteopathy 27 

a lumbar curvature, dietetic errors may cause dorsal muscular irritation 
and contraction produce a constant osseous lesion which in turn may 
result in chronic indigestion. 

The pathological changes in the osseous lesion are commonly one 
of structural derangement, deviation or complete displacement. The 
vertebral segments are of primary consideration owing to their import- 
ant relations to the spinal nerves, spinal cord centers and sympathetics; 
the ribs owing to the close sympathetic and spinal nervous relations; and 
then other osseous tissues, as the innominata, clavicles, etc., depending 
upon their importance to contiguous vessels, nerves and organs. It 
should always be remembered and emphasized that mechanical changes 
of the anatomical structures is the primary essential in osteopathic eti- 
ology; this is the one great inception of pathological variations from the 
distinctively osteopathic conception, which the osseous lesion typifies. 
Consequently the osseous lesion factor is actually a luxation (complete, 
or partial, even to a very slight degree), or malalignment of the bony 
constituents, which by virtue of their physical malposition impinge or 
irritate contiguous tissues. The essential test is the functional one, 
movement. The degree of involvement may be one of many gradations 
ranging from a slight malposition or impaction to a marked deviation 
or firm anchorage. 

Second in importance from the static requirement of support is 
the muscular lesion though from the standpoints of movement and 
dynamics it is often of the first consideration etiologically. Many inter- 
osseous lesions are the result of spastic involvement of deep seated spinal 
muscles, of fibrotic changes and of tensions and weaknesses that either 
estabHsh a rigidness of the segments, compromising nervous stimulus 
or vascular channel, or produce an imbalance of muscular tone and 
tension. In the latter instance some type of side-bending-rotation os- 
seous lesion occurs, commonly anchored within the physiologic move- 
ments of the spine. The muscular lesion may be an actual dislocation 
of either muscle or tendon, but rarely. Commonly it is a contracted, 
or tensed, or contractured muscle. The muscle, also, may be diseased 
either from primary or secondary causes through nutritional and infec- 
tious sources and thus be an etiological feature. 

The muscular lesion is caused, (a) by direct or indirect violence 
the same as the osseous lesion; (b) by atmospheric influences; (c) bj-- 
slumped posture, debihtating habits and various errors of living; (d) 
infections; (e) by reflex irritations; (f) by compensatory changes; (g) 
by disease causing hypertrophy or atrophy; and, (h) secondary to osseous 



28 The Practice of Osteopathy 

lesions, being the result of impingement to the muscles' nervous control. 
The tensed or stretched muscle may result from a separation of the 
points of origin and insertion. 

Herein the fundamental osteopathic concept is the resulting affection 
due to the physical encroachment, directly or indirect^, of the muscle 
tissue upon vascular channel or nerve fibre, or the effect upon the move- 
ment or alignment of the osseous tissue. 

Muscular contractions, displacements, and tensions play a most 
important part in acute disorders, although muscular lesions that are 
secondary to other lesions are usually taken into account when treat- 
ment is given. Muscular lesions affect, (a) blood and lymph vessels; (b) 
nerve fibres. Muscular contractions, especially, impede mechanically 
the return of the venous blood to the heart. The lesions to the nerves 
may be manifested in innumerable ways, depending upon the location 
of the muscle and the function and distribution of the nerve affected. 

Then there is the relaxed, overstretched, and atonied muscle. This 
condition results as a secondary effect to mechanical strains, these being 
so severe and constant as to cause direct stretching and possibly tearing 
of the muscle fibres. This should be distinguished from the exhausted 
or debihtated muscle, e. g., as found in neurasthenia and anemia. 

Diagnostically there are, (a) contractions of more or less area, due 
to atmospherical changes; (b) the deeply seated contractions involving 
a very small area, caused by vertebral and rib lesions; (c) contractions 
due to reflex disturbances; (d) contractions caused by postural effects 
and deformities; (e) contractions from spasms of the blood vessels as a 
result of nervous irritations; (f) contractions due to toxicit}^ of the blood. 
All of these characteristic muscular lesions give a direct hint as to both 
etiology and prognosis. 

Third, the ligamentous lesion, as a lesion per se, is usually of 
secondary impoi-tance to the osseous lesion. In chronic cases affections 
jf the capsular hgament and muscular fibrosis commonly maintain mal- 
alignment or rigidness. There are two features that should be noted 
in particular when considering this lesion; first, thickenings and ad- 
hesions; and, second, relaxations. 

The tone and integrity of the ligaments cannot but be of vital con- 
cern to the stability, suppleness, and adaptability of the bony framework 
in all physical movements. No matter how slight the osseous lesion 
may be the ligament must of necessity be involved. The osseous de- 
rangements are either a source of irritation to the ligamentous tissue, 
resulting in congestion and inflammation and hence thickening and 



k 



f 



The Practice of Osteopathy 29 

adhesions, or else the Hgaments are so strained and tensed that in time 
atony may occm\ Probably, in a fair percentage of atonied cases the 
first disturbance to the ligament is one of irritation and congestion, 
and from long continued involvement irritation is supplanted by de- 
biHty. 

Consequently the primary consideration of the ligamentous lesion 
from the etiological standpoint is the character of the tissue (hgament) 
changes. This, also, gives us a direct hint that is of the utmost value 
in prognosis. The independent displacement of a ligament is rare, thus 
ligamentous lesions from the viewpoint of purely physical displacements 
are secondary to if not an actual part of the osseous lesion. Ligaments, 
when displaced or tensed, readily impinge or irritate contiguous tissues, 
but the original cause of the structural perversion is commonly either 
the osseous or muscular lesion. Hence, whatever factors enter into the 
production of these lesions will at least indirectly produce the ligamentous 
lesion. 

Fourth, the visceral lesion is frequently overlooked as being of 
much moment as an osteopathic lesion. Visceral displacements acting 
as a source of functional and organic annoyance on the physical plane 
(structural perversion which produces and maintains pressure) alone are 
not in the least uncommon. 

Any or all of the abdominal viscera, or even the organs of the thorax, 
may be displaced (physically) pathologically. Actual displacement 
of the viscus is a prohfic source of distinct disorders and many obscure 
symptoms. True it is the organs are most frequently displaced from in- 
direct causes, but nevertheless the actual physical malposition is in turn 
a primary cause of still another train of symptoms and diseases. 

Visceral lesions are caused by, (a) vertebral lesions; (b) postural 
defects; (c) direct violence; (d) nutritional disorders; (e) childbirth; 
(f) unhygienic measures (tight lacing, heavy skirts, etc.) ; (g) congenital 
weakness. 

From the displaced heart due to valvular and debihtating influ- 
ences to the displaced liver, the stomach, the kidneys, the intestines, 
the ovaries, and the uterus, may arise a source of direct or indirect irri- 
tations, a train of apparent or masked symptoms, or a group of nutri- 
tional disturbances that include an extremely important chapter in eti- 
ology. Moreover not only may one organ alone be involved but several 
may be displaced or prolapsed as a whole as in splanchnoptosis; and 
even these in turn may be the direct cause of further organic displace- 
ments as the abdominal viscera prolapsing upon the pelvic organs. Here 



30 The Practice of Osteopathy 

is a very fruitful field for the diagnostician, for to separate cause from 
effect requires keen perception, an acute sense of touch, and above all, 
most careful weighing of all the factors that enter into the maze. 

Fifth, the composite lesion is not alwaj-s recognized as an ex- 
tremel}' important osteopathic factor. Bj' composite lesion is meant a 
structural lesion that primarily includes the osseous, muscular, and 
ligamentous tissues as a whole. This may be termed a lesion en hloc 
or en masse. 

Composite lesions are of exceedingly frequent occurrence. Indeed, 
many composite lesions are overlooked and instead of treating the en 
hloc disturbance as a consistent whole the component factors are treated 
separately with no concern or attention to the whole. 

Postm-al defects are excellent types of the composite lesion. The 
various curvatures, the tilted pelvis, etc., are representative of the com- 
posite lesion. Etiologicallj', pathological^, diagnostically, and thera- 
peutically the contour of the spine and ribs, the relation of the innomi- 
nata to the sacrum and spine, and the symmetry of the body generally 
should be recognized and appreciated. The relation of the part to the 
whole and of the whole to the part are of vital etiological concern. An 
incipient curvature may be easily overlooked, a pendulous abdomen 
neglected, and a slipped innominatum passed unnoticed wherein as a re- 
sult the entire vertebral column is malaligned in relation to the physio- 
logical curves or to the perpendicular Hne of gravity. 

Frequenth' attempts are made to correct individual lesions when 
attention should be directed to the composite lesion and vice versa, e. g., 
a displaced rib is usually dependent upon a corresponding vertebral 
lesion, and thus the transverse plane or section of the body should be 
considered as a whole. A single lesion may be dependent upon a com- 
posite lesion or a composite lesion dependent upon one or more single 
lesions. A shpped innominatum or a disordered hip joint may bring 
about a strain to a greater or less section of the spinal column, or a twisted 
vertebra may cause a curvature, whereas on the other hand postural 
defects may cause a strain at its maximum focal point resulting in over- 
stretching and relaxing of ligaments so that an osseous lesion results, or 
a spinal curvature cause an innominatum displacement. Thus there is 
a constant establishing of equilibrium, physically and physiologically, 
through the medium of compensation, but at some phase of the change 
there are apt to be pathological phenomena resulting, and verj^ frequently 
physiological harmony is not re-estabUshed but instead irritation, de- 
bility and other disease symptoms are constant effects until relieved. 



I 



The Practice of Osteopathy 31 

Consequently osteopathic etiology is many sided and complicated. 
To know whether an osseous, ligamentous, muscular, visceral, or com- 
posite lesion is primary or secondary, compensatory, reflex, predisposing, 
or exciting, requires a command of theoretical knowledge backed by 
much actual clinical experience. 

In noting the above distinctive osteopathic etiologic features the 
student should not lose sight of the constitutional status of the patient 
wliich may be modified by inherited, congenital, diathetic, and environ- 
mental influences, all of which go to make up the predisposition of the 
individual and have an impoitant relation to osteopathic factors. Then 
it should be recalled that disease processes may be of insidious pi ogress,, 
and the products and effects of pathologic changes accumulative. 

Osteopathic Pathology 

In the etiologic study the osteopathic characteristics have been 
designated structural mal-adjustment, although at the same time not 
losing sight of the angle that the body is not only a physical mechanism 
but also a vital organism. Structural perversions characterize the os- 
teopathic distinction when dealing with the physical body, and remem- 
bering the vital or bioche-mic mechanism, mental attitude, diet, hygiene, 
etc., are not forgotten. To retain or attain health, thorough apprecia- 
tion of both the physical and vital mechanisms should be kept in view, 
for there is both an independent and dependent interaction on the part 
of each. The Hving body being an entity premises a system of thera- 
peutics both physical ?nd vital, that acts in direct accord and harmony 
with physical laws and physiological functioning. 

Osteopathic pathology deals with the distinctive osteopathic lesion 
as a factor in production and maintenance of disease. Then the province 
of pathology is, first, to determine whether the lesion is in reality an etio- 
logic factor; second, the immediate character of the lesion disturbance; 
and, third, how organic life becomes involved. 

Insi)ection, palpatioi;, chnical results, dissection and laboratory ex- 
perimentation include the methods employed to prove that the lesion 
is of practical consequence. That the lesion is an etiological factor can 
be known only through clinical and experimental proof; the immediate 
character of the lesion disturbance can be determined by dissection; and 
how organic life becomes involved requires the summation of histological, 
. physiological and pathological data. 

The following outline assumes that the reader is famihar with anat- 
omy, physiology and pathology. Osteopathic pathology does not add 



32 The Practice of Osteopathy 

to medical pathology an absolutely new pathology in all of the present 
known numerous details, but instead interprets much of clinical path- 
ology anew, and furthermore it presents absolutely new data that is 
exclusive, but germane to the present general medical and surgical fields. 

Nervous tissue and arterial blood are the master tissues, the control- 
Ung and governing factors in health, and disturbances of these tissues 
are necessarily the cause of ill health. The rule of the artery and the 
control of the nerve must continue uninterruptedly in order that physio- 
logical functioning remains intact. The body should be looked upon as 
a being complete, no more or less, each tissue and organ essential to the 
whole and the organism as a whole essential to every part. This is 
fundamental and germane to a living structure, and hence disturbance 
to the governing and controlhng tissues, the nerves and vascular chan- 
nels, must necessarily cause a break in the concatenation and disease 
must logically follow. 

Thus in the osteopathic pathology we look to those influences that 
primarily disturb the nerve or artery, study the disease process or ex- 
tension from inception to effect and from primar}^ lesion to morbid results, 
and note action and interaction of tissue upon organ and organ upon 
organ. 

That all parts of the body are in intimate and dependent relations 
each with the other through the media of the nervous and endocrine 
systems is a well known fact based upon histological and physiological 
grounds. The neurone being the physiological unit implies that any 
disturbance to the cell quickty disturbs any or all of its processes. It may 
be said that " nervous tissue is dependent for its integrity upon two things, 
blood supply and trophic influences. The nerve cell is solely dependent 
on a proper supply of blood, and dies when this is withdrawn. But the 
nerve fiber is more dependent on the trophic influence of the cell of which 
it is a prolongation. It dies when cut off from the cell but it can get 
along for a time with but little direct blood supply. On the other hand, 
if the nerve fiber is injured it reacts on the cell, leading to a partial but 
curable degeneration of the cell body."^ Here is the immediate patho- 
logic key to many diseases. Whatever cuts off or obstructs the artery 
leading to the cell is a primary etiologic factor; this then leads to de- 
generation of protoplasmic processes and axone. It should be carefully 
noted that if the obstructed blood vessel is one to the nerve fiber only 
the resultant partial injury to the cell is curable. 

"When an axone degenerates the retrogressive process involves 

1. Dana — Text Book of Nervous Diseases. 



The Practice op Osteopathy 33 

not only the main axone, but also its terminals, together with the collat- 
erals belonging to it with their terminals."^ This is an exceedingly- 
important link in the explanation of osteopathic pathology, that distant 
organs may be affected by the osteopathic lesion. Moreover, "degen- 
erations of a secondary character may occur in those systems of neurones 
which are more or less dependent upon the peripheral sensory neurone 
system for their impulses. "^ This is equally true with the central motor 
neui'one, or any neurone. It shows how far-reaching a degenerative pro- 
cess and its effects may be. It further makes clear that nerve intactness 
is directly and absolutely dependent upon a normal circulation, and 
that it is self-evident any blockage either to blood vessels or to neurones 
will vitaUy affect those tissues that govern and control the life processes 
of the body. The integrative action of the nervous system is one of 
the outstanding facts of physiology. 

The above is presented so the student may see how osteopathic 
spinal lesions, if deeply seated and effective enough, can involve remote 
tissues and organs. No one will doubt that fractures and complete dis- 
locations of the spinal column will seriously affect visceral Hfe, or a pro- 
lapsed kidney will be a cause of nutritive disturbance, or a displaced 
uterus the cause of ovarian congestion, or a dislocated hip the cause of 
atrophy of the leg muscles, but it has remained for the osteopath to 
offer proof that slight misplacements of the vertebr* or ribs, incipient 
curvatures, postural defects, slight deformities, and unsymmetrical bodies 
are of sufficient etiological importance on the physical plane to affect 
neurone integrity and obstruct artery courses, and thus organic life. 

The question at once arises, what is the inomediate or direct effect 
upon blood vessel or nerve of the osseous, ligamentous, muscular, vis- 
ceral or composite lesion? The osseous lesion will be taken as a type. 
The direct effect is usually one of hyperemia or ischemia, generally the 
former, for as physiologists and chnicians observe irritation commonly 
precedes debihty. In the vertebral and rib lesions there may be direct 
pressure upon the spinal nerve at its spinal foramen exit or on the sym- 
pathetic chain directly contiguous to the heads of the ribs. This causes 
congestion, inflammation, ecchymosis, and degeneration of the nerve 
fiber, followed by macroscopic and microscopic changes as connective 
tissue proliferations, arterial scleroses, etc. Or, as seems probable in 
experimental work, the inception of the pathology may be frequently 
the result of blockage to nervous stimuU, which when maintained affects 

1. Barker — Reference Hand Book of the Medical Sciences. 

2. Delaficld & Prudden— Hand Book of Pathological Anatomj^ and Histology. 



34 The Practice of Osteopathy 

the efferent vasomotor, secretory, trophic and other fibers so that cir- 
culation and nutrition are definitely involved. 

Thus the cells so sensitive to altered vascular changes are directly 
and remotely affected, and disease characteristics dependent upon struc- 
ture and function of tissue, and degree of irritant are evident. This 
can vary, in degree only, with the muscular lesion that involves collat- 
eral spinal cord circulation, the visceral lesion that irritates sympathetic 
life, or the composite lesion that deforms or perverts structure en masse. 

But is the physical noxa as potent an etiologic factor as the chemical 
or bacteriologic? Adami^ informs us whether an irritant is physical, 
bacterial or chemical, no satisfactory distinction can be founded on the 
duration of the irritation; that a local irritation of the nervous system 
may lead apart from "direct reflex action, to changes of nervous origin, 
in the region of the injury and in the reflexes affecting associated regions, 
the higher centers; and through them the system at large, may become 
affected by paths that it is not always easy to trace." Again he says 
that "centrifugal impulses alone, apart from any local injury, may origi- 
nate a succession of phenomena of inflammation in a part." And "in 
all probability a nervous and central origin must be ascribed to some, 
at least, of the sympathetic inflammations seen to occur in areas sup- 
pHed by the other branches of a nerve supplying a part primarily inflamed ; 
and again in areas supphed from the same region of the brain or cord as 
the inflamed organ." Other inflammatory changes, of course, may oc- 
cur independently of centrifugal nervous influences, and the vessels re- 
act independently of central influences. 

This, then, presents a situation postulated thus: 

1. The body follows definite structm-al relations and is influenced 
by mechanical arrangements in its morpholog}'. 

2. The integrity of tissue depends upon structural freedom of 
nutritive courses. 

3. The above predicates a structural etiology as exact and pre- 
cise as structural relations are unportant to nutrition. 

What proof, then, of the foregoing have we to offer? 

First, the clinical proof. CHnical results have been obtained in 
tens of thousands of cases that include disease of various types and les- 
ions, and of all sections and organs of the body. The art of osteopathy 
has been perfected in many of its details, based upon actual experience 
and splendid results. The cure of the patient is paramount to all other 
cons deration, and whereas the osteopathic school has been shown a 
1. Adami — Inflammation, Allbutt's Svstem of Medicine. 



The Practice of Osteopathy 35 

superior system it logically follows on a priori grounds that relief and 
cure of suffering is of the first and final importance/ 

Were it not for clinical results no new system of therapeutics could 
withstand criticism and calumny and finally truimph and be publicly, 
legislatively, and scientifically recognized. 

Second, the autopsy proof. Many dissections have been made 
and autopsies held with the view of discovering the character and the 
potency of the osteopathic lesion. This very important work has borne 
out the osteopathic theory of disease. Vertebral and rib displacements 
have been noted, corresponding ligamentous tissues thickened, associated 
nerve tracts and vascular channels disturbed, and finally the related or- 
gan found diseased." 

Third, the experimental proof. Experimental proof appeals, 
logically, to the scientific mind. This proof ^ is being gradually developed. 

Experimental investigation has been successfully carried out upon 
numerous animals. The experiments conclusively prove that not only 
spinal inhibitory and stimulatory manipulations (mechanical) are pro- 
ductive of immediate physiological changes in the viscera, but that the 
structural anatomical lesion or noxa is an important factor in the etio- 
logic field. Pathological changes in several organs directly follow the 
artificially produced vertebral and rib lesions, showing beyond doubt 
the reality and effectiveness of the osteopathic lesion. This emphasizes 
the point that centrifugal impulses originate an inflammation in a prev- 
iously healthy and uninjured tissue or viscus. And as "inflammatory 
phenomena may be sympathetically developed in regions innervated 
from the same area in the brain or spinal cord" it remains to prove the 
actuaHty of vertebral and rib lesions, i. e., structural perversions really 
affect contiguous nerve courses and vascular channels; and this has been 
demonstrated in laboratory experiments and at the autopsy. Conse- 
quently the vertebral, rib, or other lesion may be an important etiologic 
factor either to the nerve strand from cord or brain to viscus or from 
viscus to cord or brain. 

Dr. Still says in his Autobiography that all nerves depend wholly 
on the arterial system for their quaUties, such as sensation, nutrition 

1. See Case Reports, American Osteopathic Association. 

2. Clark — Applied Anatomy. 

3. McConnell — ^Numerous articles Journal A. O. A. 1905-19, Bulletins Research 
Institute; Deason, Bulletins Research Institute, Deason's Physiology; Burns' Osteop. 
World, Aug. 1905; Basic Sciences, Bulletins Research Institute; Pearce, Osteopathic 
Physician, Nov. 1905. 



36 The Practice of Osteopathy 

and motion, even though by the law of reciprocity they furnish force, 
nutrition and sensation to the artery itself." It matters little in this 
outline whether obstruction to nervous integrity is by way of 
an impinged artery or by direct pressure, or both, or otherwise, ' for the 
primary consideration is the noting that the osteopathic lesion is a real 
and potent factor of disease. Sajous^ informs us that "a neurone is 
directly connected with the circulation (via neurogUa-fibril) by one or 
more of its dendrites, wliich serve as channels for blood plasma," that 
a neurone receives its nutrition directly from the general circulation, 
and that from the axone the blood passes into a lymph space connected 
with a vein. Thus in reality a part of the circulatory system is that of 
the entire cerebro-spinal system. 

The student is referred to the various publications of the Research 
Institute and Deason's Physiology for experimental data confirming 
the vahdit}^ of the osteopathic theory, although it should be emphasized 
that clinical evidence is quite conclusive. Malalignment injuries of the 
vertebral articulations, for example, ranging from imbalance of mus- 
cular tension to infections, is certain to result in some type of rotation 
and sidebending of the segments to an extent that apposition is com- 
promised and abnormal anchorage supervenes. There are many fac- 
tors of the pathology: muscular tension and fibrosis; damaged Hgaments, 
particularly the capsular; interference of nervous stimuU, blockage of 
impulse directly and reflexly as shown by pathologic involvement in 
cord centers and sympathetic gangha, and in certain cases direct obstruc- 
tion of nerve fibers as revealed by Wallerian degeneration; involvement 
of circulation as shown by damage to bloodvessels, local edema and 
local acidosis, and effect upon local tissue respiration and drainage. 
Through a combination of these various factors circulation, nervous equi- 
librium and chemism of related parts are involved, both anatomical and 
physiologic balance is upset, and resistance of corresponding viscera 
affected. Reciprocal innervation and the axone reflex are also dis- 
turbed, all of which are important predisposing causes that disturb re- 
sistance of tissues and organs, upset their correlated mechanisms and 
render active various possible infections and toxins that otherwise a 
normal circulation, nervous and endocrine systems, and oxygen supply 
would rapidly and successfully combat and restore the organism to nor- 
mal. Thus from the practitioner's standpoint there are three points to 
always keep in mind: readjustment of the lesion; correction of the 
forces, habits, environment, etc. that produce the lesion; and hygienic 

1. Sajous — Internal Secretions and the Principles of Medicine. 



The Practice of Osteopathy • 37 

attention of the body after lesion adjustment in order that normal con- 
dition may be maintained. A thorough study of the physiologic move- 
ments of the spine is a prerequisite to an understanding of the various 
possible abnormal appositions, though it should be appreciated that these 
movements are not consonant or applicable to many abnormal condi- 
tions. Pathology reveals many gradations and combinations not found 
in normal conditions. Frequently the key of a successful technique rests 
upon an understanding of the individual make-up of the interosseous 
lesion. 

It has not been the purpose of this section to go into details but 
rather to follow logically an outhne of osteopathic etiology and path- 
ology. The various details will be found in the osteopathic works on 
Principles as well as in the experimental articles referred to. It should 
be understood that the osteopath believes thoroughly in vis medicatrix 
naturae whether the indications are for stimulation or inhibition or for 
the basic readjustment. Generally speaking, however, therapeutic 
philosophy resolves itself (ultimately) into the principle that a cure 
depends upon giving an impetus to impaired, habitual and latent forces, 
which in the osteopathic field impHes fundamentally adjustive manipu- 
lation whereby the resultant impetus or physiological stimulus is ini- 
tiated. 

In a word, osteopathy premises that the body is a vital and phys- 
ical mechanism subject to derangements, structural alterations, and 
functional changes, as results of violence on the mechanical plane, as 
well as disturbances on the psychic and biochemic planes. Hence, os- 
teopathic philosophy is inclusive of preventive, paliative and curative 



38 The Peactice of Osteopathy 

OSTEOPATHIC DIAGNOSIS AND PROGNOSIS 

Osteopathic Diagnosis 

In osteopathic diagnosis the spine is the first and greatest object 
of interest, for on the result of its examination will depend the treatment 
to be given which is in turn hoped to bring about recovery. 

As it is the structure on which rests the weight of the body the prac- 
ticed eye is able to detect at a glance, by the poise and gait of the patient, 
if there is an abnormal condition affecting any considerable area of the 
spinal column. It is well to observe these points, especially in the fe- 
male, before having them prepare for examination, as it will often give a 
clue to sources of trouble through faulty carriage, improper dress, par- 
ticularly corset and shoes. Slight changes of gait, unnoticed by the 
patient may be of great aid in determining the beginning of disease in 
the spinal cord. 

No osteopath is justified in accepting a patient who will not permit 
every examination deemed necessary, as remote and obscure lesions are 
frequently the cause of disease, so preparation of the patient for the first 
scrutiny is of importance. This cannot be made with the patient fully 
clothed, as visual observation is second only to the touch in making one's 
deductions. Neither can palpation be made through more than one 
thickness of clothing with accuracy, and examination next to the skin is 
always preferable. This need in no way ever cause complaint, for with 
the use of a loose fitting short kimono, with all outer clothing removed 
except the knit undergarment, and with skirt bands loosed, a complete 
survey of the whole dorsum from occiput to coccyx can be had without 
the slightest unnecessary exposure. It is well to remember that the pa- 
tient has come for help and the osteopath is not justified in sacrificing 
thoroughness for any exaggerated feehngs of modesty. With tact and 
care in the use of the garments the most sensitive ones need feel no hesi- 
tation in coming for treatment. 

A complete history of the case should be taken before the examina- 
tion begins, former methods of treatment, symptoms, environment, etc., 
as it will aid in the final conclusions. It is well to have blanks for keep- 
ing records of all cases. 

Probably the most comfortable manner to begin physical examina- 
tion is to seat the patient on a table squarely with hands placed upon the 
knees, then raise the garment and expose the whole back. Begin by 
noting the texture of the skin, if it is clear, pigmented, blotched, or has 



The Practice of Osteopathy 39 

eruptions. Try the capillary reflex by pinching or stroking quickly with 
the finger tips or the blunt end of a pencil. Find if it is moist or dry 
and also outline the areas of changed temperature, if any. Then ob- 
serve the general contour of the spine with the patient sitting upright, 
to find how near it is to the normal body curve. 

Occasionally having the patient alternately sit and stand will, by 
comparison, throw fight upon the condition. With the patient bending 
forward place the hands on the crest of the ilia and see if they are of 
equal height. 

Occupation may result in over development of one side or there 
may be congenital asymmetry \ Note position of the scapulse and habit 
of posture in sitting and standing. 

Before taking up the subject of a critical examination of each verte- 
bra there are certain points it will be well to consider. It is easy to 
know instantly, without counting, the number of the vertebra causing 
the lesion if these landmarks are remembered: First, the spine of the 
third dorsal is on a level .with the spine of the scapula. Second, the 
spine of the seventh dorsal is on a level with the inferior angle of the 
scapula. Third, the spine of the last dorsal is on a level with the head 
of the last rib. It will save much time for the busy osteopath to have 
these weU in mind. 

The pathognomonic symptoms of the osteopathic lesion are: 
(a) maladjustment; (b) contracted muscles; (c) tenderness; (d) lim- 
ited movement. To these might be added changes in local temperature 
and disturbance of function, but the former is not constant and the latter 
may be remote. Here the primary lesion is considered, for an osteo- 
pathic lesion may be, also, secondary or compensatory. Forbes speaks 
of compensatory changes as being an important diagnostic sign. 

Diagnosis of the position of a vertebra is sometimes difficult to the 
beginner from its having longer or shorter spines than normal. Horsley 
speaks of the occasional congenital absence of a spinous process. They 
may be bent laterally, upward or downward and thus have all the ap- 
pearances of a marked displacement, while occasionally the body itseK 
seems much at fault. These present what might be termed normal 
abnormalities and make it necessary for the osteopath to be very sure 
of his diagnosis before attempting to correct what is not abnormal, for 
disappointment, at least, and injury, perhaps, may follow. 

To avoid mistake, carefully palpate the transverse processes and 
determine if they are at right angles with the adjoining normal spine. 

1. See Tubby, Deformities. 



40 The Practice of Osteopath's: 

In the cervical and lumbar vertebrae it is possible to reach the tips of 
the transverse processes, and on moderate pressure, if a lesion exists, 
pain will be ehcited. Further, where tenderness is associated with other 
diagnostic points it can be safely assumed that a lesion exists, and by 
outlining the suspected vertebra with the finger and locahzing the sensi- 
tive spot one can be sure of the point of greatest irritation and the char- 
acter of the displacement. Associated also with these signs will prob- 
ably be evidence of congestion, such as thickened tissues, contracted 
muscles, etc. 

After having examined the condition of the spinal column thor- 
oughly^ by inspection, begin at the first dorsal and examine the spinal 
column down to the sacrum. Place the middle and ring fingers over 
the spinous processes and stand directly back of the patient and draw 
the flat surfaces of these two fingers over the spinous processes from the 
upper dorsal to the sacrum in such a manner that the spines of the verte- 
brae pass tightly between the two fingers, thus leaving a red streak where 
the cutaneous vessels press upon the spines of the vertebrae. In this 
manner shght deviations of the vertebrae laterally can be noted with the 
greatest accuracy by observing the red fine. When a vertebra or a sec- 
tion of vertebrae are too posterior a heavy red streak is noticed and when 
a vertebra or vertebrae are anterior the streak is not so noticeable. Thus 
when suspicious points are noticed a special examination of the locahzed 
point can be given. This examination simply takes into consideration 
the contour and superficial condition of disordered portions of the spinal 
column. In a few cases such an examination will not be necessary, for 
the symptoms and signs of the disease will be so clearly manifested that 
one's attention will be called directly to the cause. StiU, great care 
should be taken in the majority of cases, as the osteopath finds causes of 
disease remote from the seat of complaint. We must always bear in 
mind the significance of reflex stimuli and sympathetic radiation. 

In making a critical and exhaustive diagnosis of the spinal condi- 
tion after the foregoing general examination has been made, it will be 
best to have the patient he on the side upon the operating table. When 
the patient is in this position a more thorough examination can be made, 
as then the spinal muscles are not contracted unless abnormally so, 
for when a person is in the upright position muscles are continually con- 
tracting first on one side and then on the other, as one of their functions 
is to act as a support in keeping the spinal column erect. The patient 
lying on his side, the physician should then stand in front of him and 
reach over upon the back and make a thorough examination of the af- 



The Peactice of Osteopathy 41 

fected portions of the spinal column, chiefly through the dorsal and lum- 
bar regions. 

Consideration should be given the contraction of the muscles along 
the back, chiefly the deeper layers of muscles. It may even be necessary 
to relax some of the muscles before a thorough examination of the verte- 
brae can be made. From a pathological point of view too much stress 
should not be put upon the contracted state of the muscles; although 
in a number of instances the contracted muscles may be the primary 
cause of the patient's trouble; especially so when the affection is due to 
atmospheric and other changes. Contraction of the muscles may be 
secondary to the lesions presented in the bony frame work. For in- 
stance, a dislocated vertebra may be the cause of an irritation to the 
innervation of certain muscles along the spinal colmnn and thus cause 
them to contract. Still, we must not lose sight of the importance of the 
contracted muscles from a diagnostic point of view. They are often- 
times prominent signs that a lesion exists in the immediate region and 
are thus faithful guides in locating the cause of diseases. 

In closing the general consideration of the spinal column it is well 
to emphasize the importance of training the faculties to grasp at a glance 
the story told by the back as a region, instinctively placing the proper 
value on each physical sign and weaving them into a composite whole 
so that the patient's condition stands out a vivid picture on the osteo- 
path's mind. When this is accomplished the more detailed observations 
are but incidental. Relative to the examination of the spinal column 
Clark^ says: "To the osteopathic physician, the most important part 
of the human body is the spinal column. By its changes in contour and 
condition the various visceral diseases can be diagnosed, in most cases. 
I believe that every disease is characterized by extreme changes or signs, 
and I further beheve that every chronic visceral disorder is manifest by 
changes in the spinal column that can be, by the practical eye and touch, 
readily interpreted. In short, there are various signs along the spinal 
column that point out the weakened or diseased parts of the body. This 
method of diagnosing disease, that is by noting these spinal changes, 
is distinctly osteopathic, and I beheve the time will come when it will 
become such an exact science that the character of the spinal change or le- 
sion is diagnostic not only of the viscus affected, but the way it is affected." 

Regional examinations and diagnosis will now be taken up. 

Neck, Head and Face. — To make a thorough diagnosis of the con- 
dition of the cervical vertebrae probably requires more skill and a more 
1. Clark's Applied Anatomy, p. 334. 



42 The Peactice of Osteopathy 

acute sense of touch than of any other region of the body. The irregu 
larities and variations of the cervical vertebrae, the numerous muscles 
and the passage of many vessels through the neck are very liable to mis- 
lead one. 

One may examine the cervical vertebrae by having the patient either 
lying down or in a sitting posture. The former position is preferable, as 
then the muscles of the neck are passive, and besides it is much easier 
to relax the muscles if such should be necessary. Also one has better 
control of the field of examination. 

It is undoubtedly best for the student when learning to examine 
the cervical vertebrae to first examine along the base of the skull the con- 
dition of the occipital muscles (after the patient has assumed the dorsal 
position upon the treating table) for any contractions; for if disorder ex- 
ists in the upper five cervical vertebrae the condition will be manifested 
by contraction of muscular fibres along the base of the occipital bone. 
The muscles of the occiput are suppHed by fibres from the posterior 
branches of the upper five pairs of spinal nerves, and if lesions exist to 
these upper nerves a contracted state of more or less extent of the oc- 
cipital muscles will occur, no matter how shght the lesion. Thus the 
examiner after locating contracted fibres under the occiput has a direct 
clue to lesions existing somewhere in the upper five cervical vertebrae. 
After locating these contracted fibres of the occipital region and then 
still keeping the finger upon the contracted muscular fibres and follow- 
ing them downward until the contractions are lost and seem to enter the 
spinal cord, one has then located the exact point of disorder that is caus- 
ing the irritation to the muscular fibres involved, and most probably the 
cause of the affection from which the patient is suffering, i. e., provided 
one has reason to suspect the trouble is in the cervical vertebrae. Simply 
follow the contracted muscular fibre downward until it seems to enter 
the spinal cord and there one will find a lesion. After the osteopath has 
become expert in diagnosis this will not be necessary unless he has to 
make a very fine diagnosis or unless he is examining a stout neck where 
it is hard to examine through the heavy muscles. With this method 
one has a firm, flat, broad surface to work on (the occipital bone) making 
it very easy first to locate contracted muscles and second to trace the 
course of contracted muscles and thus find the disorder. Otherwise the 
beginner is apt to get confused by trying to examine the condition of 
the cervical vertebrae. Later, when a student becomes more expert such 
a procedure will rarely be necessary only in cases that require special 
work in the examination. 



The Practice of Osteopathy 43 

When the point of disorder has been located the diagnosis as to the 
3xact character of the maladjustment has to be determined. The ab- 
normal position of the vertebra, tenderness at the point involved, local 
contracted muscles, and Hmited motion are the four diagnostic points, 
although the temperature of the affected part as compared with the 
general cutaneous temperature and the state of the local vascular chan- 
nels (blood and lymphatics) will occasionally be of aid. 

Owing to the irregularity of the spinous processes of the cervical 
vertebrae in regard to their length, great care has to be taken in the' ex- 
amination. Probably there is no other region of the body that will tax 
the patience of the osteopathic student so much in his practical work as 
making a diagnosis of disorders in the cervical, spine. It requires patient 
and persistent work to become a fair diagnostician of the cervical region, 
and it will take much experience to become expert in both the examina- 
tion and treatment. 

One can depend that lateral deviations of the spinous processes are 
abnormal in most instances. Placing the finger upon the spinous pro- 
cesses of two consecutive vertebrse the student can readily tell whether 
or not there is any lateral displacement; but telling as to other features 
is impossible as the spinous processes vary greatly in length. When a 
vertebra is lateral, a shghtly twisted condition will be felt by the finger 
when placed upon and between the two spinous processes. 

To elicit the various degrees and combinations of rotation and side- 
bending one should depend upon the symmetry of the transverse pro- 
cesses. Reaching anterior to the sterno-cleido-mastoid muscle, or bet- 
ter still, pushing the cleido muscles forward and reaching posterior to 
them upon the transverse processes, a very fair examination can then be 
given the vertebrse. When the vertebrse are deranged, especially anter- 
iorly or posteriorly, that is the apposition of the articular facets, a slight 
elevation will be felt, possibly not any larger than a very small pea, either 
the anterior or posterior aspects of the transverse processes, depending 
upon which way the vertebrse are deranged. Remember that accom- 
panying this slight elevation will be degrees of sensitiveness of the 
vertebra at the point deranged. In cases where the vertebra 
is lateral a slight eminence will be noted along the outside of the 
process. Commonly disordered vertebrse are not entirely deranged in 
one direction but are oftentimes slightly rotated, so we may find them 
''dislocated antero-laterally or in various combinations of sidebending- 
rotation. Several consecutive vertebrse may be deranged in like manner 
of direction; this condition is chiefly found in pathological curves of the 
spinal column. Probably the most common general lesion is a strained 



44 The Practice of Osteopathy 

condition of several consecutive vertebrae, each one being nearly intact 
but all of them as a whole somewhat strained or twisted. Thus there 
are many pathological states to take into consideration, although it is 
not surprising to the osteopath when he realizes that many of our pains 
and aches are due to anatomical derangement. Frequently bending 
the head strongly forward and downward, or downward pressure with 
slight rotation will produce pain at the point of lesion. 

Sub-dislocations of the atlas are probably among the most common 
lesions presented to the osteopath. Owing to the articulation of the 
atlas and occipital bone being an anatomically weak point and the neck 
muscles being exposed constantly to atmospheric changes, besides the 
articulation between the. head and neck receiving the brunt of many 
jars, falls and strains, the atlas is especially susceptible to derangements. 
On account of the intimate relation of the atlas to the superior cervical 
gangUon of the sympathetic and to the vertebral blood vessels it is cer- 
tainly very necessary that the atlas should be well taken care of. No 
other tissue maintains such a significant position in relation to the blood 
and nerve supply to and from the brain. To diagnose correctly the 
position of an atlas and to be able to correct it is undoubtedly one of the 
most essential achievements of the practitioner of osteopathy. 

The most common disorders of the atlas are anterior and lateral 
displacements. Next in order come "rotary" lesions of the atlas, i. e., 
where the atlas has been deranged diagonally or simply twisted. It 
may also be luxated anteriorly and laterally, or posteriorly and laterally, 
etc. A posterior derangement of the atlas is comparatively a rare dis- 
order, although owing to the many lesions that are found in atlases one 
has, during the course of a year's practice, several to correct. The atlas 
ma}^ occasionally be sMghtly tipped lateralty, anteriorly, or posterior^, 
and in a few cases it may be somewhat impacted against the occipital 
bone. Many times when the atlas is displaced the axis is also deranged 
on account of the close relation between the atlas and axis by the odon- 
toid process of the axis. 

To examine the atlas the patient may be either in the sitting or dor- 
sal posture; it matters but Uttle which position is taken. Possibly the 
dorsal position is better, as then the neck muscles are more relaxed and 
if necessary an examination of the cervical spine, below the atlas, can 
easily be made. 

By placing the middle finger of either hand on the transverse pro- 
cesses of the atlas when the patient is in the sitting posture, or the thumbs 
on the transverse processes when the patient is in the dorsal posture and 



The Practice op Osteopathy 45 

comparing the two sides, undue prominence of one side or the other can 
easily be noted. Remember the transverse processes of the atlas are 
shghtly above and posterior to the angle of the inferior maxilla. Always, 
in examining one side of the patient, compare it with the other; it may 
save considerable embarrassnlent. One side may seem abnormal when 
by comparing it with the other side, both sides may be found the same 
and still be normal. With the fingers still on the transverse processes 
note the distance between the process and angle of the jaw, besides take 
into consideration the tenderness of the locahty, and, also, what is of 
essential importance in all interosseous lesions, its articular range of 
movements. There should be room enough (approximately) to just 
comfortably wedge the end of a medium sized middle finger between 
the transverse process of the atlas and the angle of the inferior maxilla 
when both are normal. Thus with the fingers on the transverse processes 
an expert will be able to readily determine whether or not an atlas is 
lateral or anterior. If an atlas is posterior the distance between the 
angles of the jaw and the transverse process will be increased, besides 
the atlas will be quite prominent posteriorly. In conjunction with the 
abnormality of the tissues (prominence or depression of the bone and state 
of the muscles) the sensitiveness of the locality is extremely significant. 

Outside of displacements of the atlas, a lesion between the axis 
and third cervical is most common; following next in frequency are 
lesions of the skull and atlas. By that is meant where all the cervical 
vertebrae are intact as far as their individual relation is concerned, but 
the skull is forward, backward or lateral upon the spinal column. This 
condition occurs quite frequently. To determine its condition the same 
methods are employed as in diagnosing a deranged atlas; for if the dis- 
locations exist between the atlas and skull the same diagnostic points 
are presented as far as the skull is concerned as when the atlas, or atlas 
and axis, are dislocated from the occipital bone or from the axis or third 
cervical. Following the preceding examinations, additional examina- 
tion will have to be made to see whether or not the atlas is intact with the 
vertebrae below. If the atlas is found to be intact with the vertebras 
below and lesions are presented between the atlas and the skull, then 
the disorder must be between the atlas and the skull and nowhere 
else. Occasionally there are cases where the skull is so far posterior 
upon the spinal column that the angles of the jaw strike against the 
transverse processes of the atlas when the jaw is opened widely. 

Derangement of the muscles of the anterior and lateral regions of 
the neck are common. Especially are contractions of the muscles on 
either side of the larynx liable to occur. In examining the cervical region 



46 The Practice of Osteopathy 

do not pay too much attention to the superficial muscles, but examine 
carefully the deeper muscles. It is from these that impingements of 
nerves and constrictions of vessels are likely to take place in the con- 
tracted fibres. Also, imbalance of muscular tension may be the source 
of the resulting malaUgnment. In examining for contracted muscles 
do not gouge into the muscle nor grasp the muscle roughly, but bear 
down hghtl}^ (inhibitory) upon the muscles and then gradually exert 
firmer pressure. By carefully and firmly exerting pressure over mus- 
cular areas the deep muscles can then be felt beneath the superficial 
ones. Otherwise when the muscles are manipulated severely the super- 
ficial ones will contract to such an extent that the deeper ones cannot be 
felt. The muscles contracting on either side of the larjiix tend to draw 
the larynx downward and thus there may arise a source of irritation. 
The various muscles contracting in the antero-lateral region of the neck 
are very often the source of chronic irritations of the pharynx or throat. 
The omo-hyoid muscle may become contracted and cause sUght trac- 
tion on the hyoid bone and thus produce an irritating cough. To ex- 
amine the muscles of the neck thoroughly it is best to have the patient 
flat upon the back, for then all the normal muscles are relaxed. 

Lesions quite frequently occur in the temporo-inferior maxillary- 
articulation. The lesion may be either unilateral or bilateral, more 
commonly the former. The disorder usually consists of a relaxation 
of the muscles and ligaments about the articulation which allows a sHght 
but perceptible dropping of the inferior maxiUa on the side involved. 
In other cases there may be presented a spasticity of tissue, while in still 
others some degree of joint infection may be found. Lesions of this 
articulation particularly impinge upon fibres of the fifth cranial nerve. 
The points of diagnosis are cUcking and tenderness at the articulation. 
These two points are the symptoms of which the patient complains; 
those noticed by the osteopath are a shght deviation of the jaw to one 
side or the other when the jaw is opened and a flinching of the patient 
due to tenderness when pressure is exerted over the articulation of the 
jaw. When the physician places liis fingers around the jaw, anterior 
to the angles, and the thumbs over the bridge of the nose, having patient 
open the mouth, at the same time exerting pressure with the fingers and 
thumb, a sharp cUck may be elicited by the return of the jaw into its 
articulation. 

In disease of the scalp the condition of the muscles of the scalp 
should be taken into consideration. The muscles are usually found 
contracted. The contraction of the muscles is generally due, as well as 



The Practice of Osteopathy ^ 47 

the disease of the scalp, to derangement existing in the posterior 
branches of the upper five pairs of the cervical spinal nerves. 

In the neck, anteriorly the hyoid is the only bone to consider. 
It is easily palpated by standing at the head of the table and with the 
second finger of each hand outhne both ends to ascertain its relation 
with the thyroid cartilage. Note carefully any contracted tissue or 
glandular enlargements which might cause undue tension. The tilting 
of either end of the hyoid from these contractions is productive of much 
throat irritation. At the same time the larynx may be examined. It 
may be prolapsed, causing irritation of the laryngeal group of nerves. 
The thyroid and cervical glands should be palpated for enlargements, 
and all the muscles and hgaments for contractions. Externally the 
tonsil may be felt by deep pressure in front of the angle of the inferior 
maxilla. 

The Ribs. — Under the osteopathic diagnosis of the ribs will be in- 
cluded the examination of the clavicle and sternum. To be able to diag- 
nose intelHgently, the position of the ribs in detail is very necessary to 
the osteopath. Many of the diseases of the heart and lungs, besides a 
large number of the diseases of the digestive tract, may be traced to a 
deranged lib; also, occasionally diseases of different regions of the head 
and neck may be due to dislocated ribs. In making a thorough examina- 
tion of the ribs each rib should be carefully noted as to its position. The 
ribs may be examined when the patient is sitting up; but it is better to 
have the patient flat upon the back and especially so if the floating ribs 
are to be carefully examined, because the muscular tissues of the side 
if contracted will interfere with the diagnosis. In many instances the 
rib lesion is secondary to a vertebral subluxation. 

An expert osteopathic diagnostician will be able to detect at once by 
a single passage of the hands down over the ribs if there are any disorders 
of them. In passing the flat of the hand, especially the flat part of the 
fingers over the ribs, carefully observe if the intercostal spaces are too 
narrow or too wide, and if any of the ribs are unduly prominent or de- 
pressed. If an intercostal space is too narrow it shows that the ribs on 
either side of the intercostal space are too close together. Then the ques- 
tion arises, which one of the ribs is crowding upon the intercostal space, 
or whether both of the ribs are crowded together. Usually when the 
sternal end of the rib is displaced upward, the involved rib is prominent 
and when displaced downward the rib is depressed. Thus it is commonly 
easy to diagnose which is the involved rib. Besides finding an abnormal 
position of the rib there will be more or less tenderness over the rib. 



48 The Practice of Osteopathy 

Finding a rib prominent or depressed and tender is generally quite con- 
clusive that the rib is displaced. Then the range of movement as ex- 
pressed through the sense of resistance is a helpful guide in dignosis. 

If a typical rib is placed upon a fiat surface and one end of it is de- 
pressed the other end will be elevated and vice versa. This peculiarity 
holds true as well when the ribs (typical) are dislocated in the living body. 
If the anterior end is elevated the posterior end is commonly depressed 
and vice versa. Care should be taken in examining the first rib and the 
false ribs, for in these ribs this pecuharity is not found. 

As a whole a very complete diagnosis can be made of the condition 
of the ribs by examining the anterior part of the thorax, although it is 
always best to examine along the angles of the ribs if for nothing more 
than to confirm the diagnosis made at the sternal ends. Still it must be 
remembered that the preceding only holds good when the entire rib is 
dislocated. Many times simply one end of the rib is deranged and the 
other end is practically intact. 

Besides careful examination of the sternal end of the rib, attention 
should be paid to the condition of the costal cartilages. The costal 
cartilages may become deranged at either the articulation with the rib 
or with the sternum. The same rule holds good when the costal carti- 
lages are dislocated as when the ribs are dislocated, i. e., when the car- 
tilages are prominent, they are usually displaced upward and when 
depressed the cartilage is displaced downward toward its neighbor. 

One is apt to think that a rib is only dislocated at its vertebral end. 
Although lesions of the vertebral end are generally of greater significance 
as far as the etiological factors are concerned, still the sternal end of 
the rib must not be overlooked. In examining the vertebral end of a rib 
attention should be paid the angles of the ribs, for at the angles a better 
opportunity^ for examination is given on accovmt of the prominence. It 
will be necessar}^ in many cases to find out whether or not the vertebral 
end of the rib is lying between the transverse processes instead of in front 
of them. In many severe lesions of the ribs the vertebral end of the rib 
is dislocated upward or downward from the transverse process of the 
vertebra and lies between the transverse processes of the vertebrge above 
and below its attachment. This certainly requires considerable skill in 
the diagnosis, for oftentimes the point to be found is barely an eighth of 
an inch in diameter. It is usually best before making such a close ex- 
amination to relax the tissues well over the field of examination. 

The rll>s as a whole may be too transverse or too obhque upon one 
side. This is chiefly found in pathological curves of the spine, but still 
such conditions may exist where there are severely contracted muscles, 



The Peactice of Osteopathy 49 

especially in some cases of paralysis. Thus the contour of the ribs must 
be taken into consideration by comparing one side with the other. 

In examining the first rib an examination somewhat different from 
the other ribs should be given. It is best to have the patient assume a 
sitting posture; then place the middle fingers of each hand upon the first 
ribs near their centers and compare one with the other. Also note the 
difference of the spaces between the ribs and clavicles. Generally the 
first rib is dislocated upward, rarely downward. Besides finding an 
abnormal prominence or depression of the rib at its center considerable 
tenderness will be noticed. Examinations of this region are every day 
experiences with the osteopath. 

When diagnosing the position of the floating ribs it is best to have 
the patient lie flat upon the back with the thighs flexed upon the abdo- 
men, so that the tissues about the lower ribs may be entirely relaxed. 
Then by placing the flat of the fingers carefully over the ribs the outline 
and position of them can be easily discerned. The floating ribs are often- 
times found deranged and are the source of a great deal of suffering 
through the iliac regions. These ribs may become dislocated from the 
vertebral ends and drop down obliquely toward the iliac crest, or else the 
free end may become locked beneath the rib above. Occasionally both 
ends of the rib drop down quite perceptibly and consequently is the cause 
of considerable distress. In such instances the rib is depressed inward 
so that the normal contour of the lower thorax is lost. 

An examination of the clavicle should be carefully made. Always 
compare the clavicle with its fellow and examine thoroughly its articu- 
lation with the sternum as well as at the acromial prominence. Often 
the sternal end of the clavicle is slightly dislocated posteriorly to the 
sternum; although it may become completely luxated. The acromial 
end may be dislocated upward or downward. 

In examining the sternum special attention should be given the 
articulation of the manubrium and gladiolus. This is due to the crowd- 
ing anteriorly of the articulation of the sternal parts. Normally until 
wefl along in adult hfe there should be some movement here due to its 
membranous attachment. Occasionally the ensiform cartilage is turned 
inward, producing a tender point, but this rarely occurs. Also the ar- 
ticulation of the cartilages in the region of the eighth, ninth, and tenth 
ribs may be found considerably deranged, causing local tenderness and 
even stomach trouble. 

Dorsal and Lumbar Spinal Region. — With the patient sitting 
on the table abnormal deviations can be readily noted. There may be 



50 The Practice of Osteopathy 

lateral swerves, from muscular weakness, or unilateral tension, involving 
the whole spine or less, or a reversal of natural curves, i. e., the spine 
depressed anteriorly between the shoulders and posteriorly in the lumbar 
making the straight spine. There may be, also, an exaggerated normal 
curve in the dorsal region producing a kyphosis with a compensatory 
lordosis in the lumbar region sufficiently great to change its relations with 
the pelvis. By the method previously given, now outline the spinal 
column for lateral and bilateral scohosis. These, frequently, are at their 
incipiency, and to the casual observer would pass unnoticed. It is well 
to make an outline of the spine before beginning treatment, and at times 
following, that progress may be observed. A simple method is lead 
tape which can be had from any plumber shop and can be molded to the 
deformity and traced on paper together with date of examination. H. 
F. Goetz has perfected an apphance for outhning and recording 
these deviations. Observe well the hgaments, as well as extent of joint 
movement, under deep palpation; from irritation they may become 
thickened and more or less fill the spaces about the spines and trans- 
verse processes, causing a rigid, smooth spine. 

To make a detailed examination the patient should be stretched out 
on one side upon a treating table, although the general examination may 
be sufficient. Then, standing in front of the patient and reaching over 
him, a most careful diagnosis can be made. Do not stand back of the 
patient as the flat of the fingers can not be used to advantage in outhning 
the different vertebrae. The various contracted muscles that may be 
found along the spinal column will be of valuable aid in locating de- 
rangements of the vertebrae and vertebral ends of the ribs. By using 
contracted muscles along the spinal column as a guide for locating lesions, 
reference to the large superficial muscles is not made, but to the small 
areas of contracted fibres of the deep muscles. It is the deep muscles 
that become more or less contracted, and even fibrotic, when lesions of 
the vertebrae and ribs exist. The superficial muscles are generally con- 
tracted by atmospheric changes, slumped postures, wrong habits, etc., 
and are not generally the result of disorders in the osseous system. The 
preceding points in regard to contracted muscles cannot be too carefully 
observed for there is a tendency among many osteopaths to treat the 
contracted deep muscles as primary lesions in nearly every case. Re- 
member that if they are not due to the motor nerve fibres of the muscles 
being irritated by the spinal lesion, or to a reflex stimulus, or to a com- 
pensatory change, that although the muscular tension may be the in- 
ception of the almost certain interosseous lesion, still the leverages se- 



The Practice of Osteopathy 51 

cured through bony adjusting are very essential hot only in correcting 
the osseous malposition but in loosening and releasing fibrous muscles 
and thickened Ugaments. 

Thorax. — Examination of the thorax as a region has been largely 
gone over in speaking of the ribs and their sternal attachment, cartilages, 
sternum and the clavicles, but its appearance as a whole should be care- 
fully noted for it will be a valuable aid in diagnosis. Deviations from 
the normal, such as the emphysematous or barrel-shaped chest in asth- 
matic affections, or chronic cough, or accompanying kyphosis, the flat 
chest and its association with phthisis, the rachitic, etc., should be con- 
sidered. Spinal deformities are reflected in the thorax by marked chang- 
es in contour, such as elevations and depressions corresponding to the 
spinal changes. These result in marked interference with the thoracic 
organs and in young subjects are of particular interest. Rib changes are 
frequently the result of vertebral deviations. 

Abdomen. — The position for examination of the abdominal viscera 
is usually with the patient supine, head slightly elevated, knees 
drawn up partially and supported to reheve any muscular strain, and 
with the hands at the sides. In this position complete relaxation is 
obtained. Observe any enlargements from gas, fluid, or tumor, muscular 
changes, color, etc. The patient may, also, be placed upon the side, and 
in the knee-chest position for further verification of the diagnosis. 
Where the abdominal wall is much relaxed, or there is a pendulous ab- 
domen with enteroptosis, there will be found a change of relations of the 
viscera b}^ these different positions, allowing them to be palpated in 
another position. When there is marked tenderness it is often possible 
to go deeper with less discomfort with the patient in the knee-chest posi- 
tion. The Trendelenburg position may also be utiHzed. Where ascites 
is suspected palpation should be made with the patient in various posi- 
tions in order to note changes of location of the fluid. Frequently much 
can be learned by inspection with the patient standing. Clues to visceral 
disturbance can often be had by tracing the nerve connection from the 
spinal lesions to the suspected part. 

In examining the liver care must be taken that any gouging or se- 
vere bruising of the organ does not take place. The fiver can be out- 
lined by percussion and also by palpation of its lower and inner borders 
Congestions, atrophy, enlargement or hardening should be noted, also 
smy change in position. 

A rather complete examination can be given the biliary tract 
from the gall-bladder to the duodenal orifice of the biliary duct. 



52 The Practice of Osteopathy 

By a careful inhibitory pressure over the duct the outhne of the tract 
can be discerned providing the patient is not too stout. When the tract 
is swollen considerable tenderness will be present. The patient will 
complain of a stabbing or piercing pain upon pressure and manipulation 
if the duct is inflamed. 

Usually the tenderness is greatest nearer the duodenal orlbce. 
The duodenal orifice is about one and one-half inches diagonally down- 
w^ard to the right from the umbihcus. In cases of impacted gall-stones 
the osteopath as a rule has very little trouble in locating the stone. 

The spleen may be percussed and when in a markedly enlarged 
condition its lower border can be palpated. Great care must be used in 
the latter condition as there is danger of rupture. 

In examining the stomach the usual methods of inspection, palpa- 
tion, percussion, analysis of the contents, etc., are employed. 

Palpation and manipulation over the intestines are practiced a 
great deal by the osteopath in various intestinal diseases. By his edu- 
cated sense of touch he is usually able to locate at once any impactions 
of fecal matter. Such impactions are generally found in the ilio-cecal 
and sigmoid regions. In the various acute obstructions from invagina- 
tion, tmnors, twists, adhesions, spasticity, knots, etc., many times one 
is able to readily locate the seat of the disturbance. There is one point 
to specially emphasize; that is, do not overlook prolapsed regions of the 
intestines; such occur frequently and are a source of considerable dis- 
tress, especially constipation. Simple manipulation will never do much 
good, neither will spinal treatment or injections, as a rule. A specific 
treatment must be given and, that is, after locating the exact point of 
prolapse, to reach carefully beneath the fold and replace it. 

In emaciated subjects the kidneys can be readily located, and in a 
few instances when they are diseased one can feel the contracted tissues 
about them. Be very careful not to injure the capsule about the kid- 
ney. Do not punch or gouge them in the least; but locate the Iddneys 
by a careful inhibitory palpation. 

Lumbar and Pelvis. — The intimate relation between the lumbar 
spine and pelvis make a consideration of them as a region necessary. 
Outside of ordinary curvatures involving both the dorsal and lumbar 
regions there are certain conditions which involve but one structure 
and require careful differential diagnosis to determine whether the lumbar 
or pelvis is at fault. In the former the fifth vertebra is a weak point 
and is most frequently at fault. The deviations are usually a sidebending 
and frequently accompanied with some rotation. Occasionally a mal- 



The Practice of Osteopathy 53 

structure of the lower lumbar or pathologically relaxed Hgaments will 
approximate the spines and be misleading as to the real condition. A 
rotation or lateral tilting of the fifth lumbar may have the effect of ele- 
vating the crest of the iUum so that the innominatum would appear in- 
volved. There will be a difference in the length of the legs, angles of 
feet when patient is lying on the back, anterior spines out of hne and 
tenderness of the muscles attached near them. However, other diag- 
nostic points of innominate lesions, i. e., tenderness of symphysis and 
sacro-ihac articulation, and prominence of the posterior spine, will be 
lacking. Marked deviation of other lumbar vertebra? may produce 
practically the same effect, but the lesion will be so apparent that there 
will be no doubt as to the cause. 

To be able to diagnose accurately and intelHgently the pelvic region 
requires nearly as much skill as in examining the cervical region. The 
pelvic bones are Hable to many subdislocations, especially in the female. 
However, it should be remembered that many apparent innominate 
lesions are secondary or compensatory changes due to lumbar lesions. 
The pelvis as a whole may be tipped anteriorly or posteriorly upon the 
spinal column. It also may be twisted or rotated laterally upon the 
spinal column. The most common lesions are subluxations of an in- 
nominatum forward, backward, upward, or downward, or various com- 
binations of these displacements, such as a tipping forward and downward 
of an innominatum, or a tipping backward and upward, but these com- 
binations do not always exist in the manner given. As a rule when the 
ilium is anterior, the ischium posterior, then the innominatum as a whole 
is downward; when the ihum is posterior, the ischium anterior, then 
the innominatum as a whole is upward. This is only a rule, there are 
exceptions to it; for in some few cases when the ihum is anterior, the 
ischium posterior, the innominatum may be higher, and when the ihum 
is posterior and the ischium anterior the innominatum may be lower. 

To be able to diagnose such derangements will require skill and prac- 
tice; still there are symptoms and signs that are characteristic of such 
disorders. In examining the pelvic bones have the patient flat upon the 
back at first. Be sure he is flat upon the back for a very shght varia- 
tion may make considerable difference in the relation of the pelvic bones, 
one to the other, so far as the diagnostic points are concerned. Then go 
to the feet of the patient and grasp the ankles firmly, rotate laterally 
both legs, first to one side and then to the other, as well as pull and push 
both limbs shghtly, and then bring the heels together directly in the 
median line of the body and compare the length of the limbs at the heels. 



54 The Practice of Osteopathy 

If there is any disorder whatever in one innominatum, and the thigh 
muscles have been relaxed thoroughly by the preceding movements and 
the heels are brought together in the median line of the body, a difference 
in the length of the limbs will readily be observed at the inner malleoli 
or the heels. For if the ihum is forward the ischium must be backward 
and as a rule the innominatum is thrown downward, thus causing an 
apparent lengthening of the limb which will be noticed by comparing 
the heels; if the ihum is backward the ischium must be forward and as a 
rule the innominatum is then upward, causing an apparent shortening 
of the limb on the affected side. A very slight variation in the pelvis 
will make considerable difference in an apparent lengthening or short- 
ening of the limbs. Such conditions are generally met with several 
times a day by osteopaths. The object of the lateral rotary movement 
and the pushing and pulHng of the limbs is to make sure that all the 
thigh muscles are thoroughly relaxed, for it is a very easy matter for 
contracted muscles in one thigh to produce an apparent shortening of the 
limb. Also be very careful in comparing the length of the two limbs at 
the heels where they come together that they are exactly in the median 
hne of the body, for if they should be to one side or the other, however 
shghtly, there would be an apparent lengthening of the outer limb as 
compared with the hmb near the median hne. While the patient re- 
mains flat upon the back it is a good plan to compare the anterior spines 
of the iUa. It may be readily noticed that one is higher or more depressed 
than the other, which will help to confirm the diagnosis. It is a good 
plan also to have the patient sit up squarely upon the table and compare 
the crests and posterior spines of the iHa; thus one may be seen to be 
higher than the other. Then, also, note the angles of the feet when pa- 
tient is supine; an everted foot usually means that the limb is shorter 
due to the tilted pelvis; the opposite is commonly true when the foot is 
inverted. However, this is not an absolute rule. Care should be taken 
in differential diagnosis of possible old fracture of leg, of infantile paraly- 
sis, of asymmetry, etc. 

There are three diagnostic points exclusive of all other signs that 
are quite conclusive when coupled with the preceding examination. 
If an innominatum is dislocated or subdislocated there will be tenderness 
over the symphysis pubis on the side affected, tenderness over the ilio- 
sacral articulation on the side affected, and tenderness along the crest of 
ilium where the abdominal muscles are attached. When tenderness is 
found at these three points it is quite conclusive that the innominatum 
is deranged, for at the symphysis pubis and iho-sacral articulation ten- 



The Practice of Osteopathy 55 

derness must exist if the innominatum is disturbed, and by a change in 
the crest of the ihum the abdominal parietes will be affected, provided 
they are not too much debihtated. Marked tenderness of the external 
cutaneous nerve as it passes over the crest of the ilium below the anterior 
spine will be noticed on the unaffected side (Dr. Still). There will be, 
on rectal examination, marked tension of the tissues on the affected 
side. Possibly the patient may complain of pain exclusively in one side 
along the pelvis and hmb which will be a leading symptom telHng which 
side is affected. 

Additional diagnostic signs will be rigidity of muscles along the 
ilio-sacral articulation and abnormal prominence or depression of the 
ilium at its articulation with the sacrum, depending upon which way the 
innominatum has sHpped. Considerable deviation of the pubic bones 
may be noticed. The pubic bone on the side affected may be either 
thrown upward or downward. 

Radiographs have repeatedly revealed subluxations of the innomi- 
nate bones in many instances. This is certainly quite conclusive in con- 
firmation of the osteopathic ideas in regard to the pelvic bones becoming 
dislocated. 

Sacrum. — Examination of the sacrum is best made with the patient 
lying on the side, with the osteopath standing in front and with the hand 
palpate its posterior surface. In the sitting posture its relation with 
both innominates can be determined. It is displaced posteriorly but 
seldom, the most frequent being anterior, downward, and a combination 
of the two. In the anterior conditions tenderness at the sacro-iliac articu- 
lations is a good point, but it must not be confounded with an innominate 
lesion. The downward displacement is shown by comparison with the 
lower lumbar vertebrae. Observe the relation between the two, as a 
change in contour of the spine will also change the angle of the sacrum 
and vice versa. 

Coccyx. — With the patient and operator in same position as for 
the sacral examination outline the coccyx, as to first, contour; second, 
rigidity, third, sensitiveness. If abnormahties are detected go to 
the other side of the table and with a well lubricated index finger palpate 
its anterior surface. Changed contour, displacements, and old frac- 
tures can be readily determined. The most common deviation is an- 
terior at its union with the sacrum. The lateral form generally result- 
ing from muscular contraction is next, with posterior but seldom. "If 
the lower part of the sacrum is rotated backward, the sacro-coccygeal 
articulation or angle is affected or becomes more acute, since the tip of 



56 The Practice of Osteopathy 

the cocc3^x is not displaced, but held in position by structures attached 
to it. If the sacrum is displaced downward the effect is about the same. 
Often this sort of sacral lesion is mistaken for an anterior luxation of 
the coccyx."^ Remember that normally there should be some move- 
ment of the coccjrx. It has a fibro-membranous articulation. 

Uterine, ovarian and rectal examinations are largely of the same 
natm-e as those given by other practitioners, although osteopaths find 
that oftentimes other practitioners are mistaken in regard to the etiology 
of many diseases to which these organs are subject. 

Arms and Legs. — There is comparatively little that is exclusively 
osteopathic in regard to the diagnosis of disorders of the arms and legs. 
One important feature that the osteopath finds in examining the arms 
and legs is that many of the disorders supposed to originate in the af- 
fected member are found to be caused from vertebral or rib dislocations. 
Innominate and lumbar lesions are particularly fruitful sources of trouble 
in the legs and feet. Always carefully examine the spine in the region 
of innervation to the arms and legs when they are affected. The shoul- 
der and hip joints, as well as all joints, are subject to partial dislocations. 
Many times when pain or other symptoms are presented in the arms or 
legs the trouble is at the shoulder or hip joint or in the spinal column. 
There are two regions that are very apt to be overlooked in the examina- 
tions of the arms and legs and they are the elbow joint and the fibula. 
The small bones of the ankle and wrist as well as of the foot and hand 
are subject to many dislocations which are easily discerned upon ex- 
amination and often overlooked. Special emphasis should be given in 
regard to many supposed diseases of the knee joints which are really 
caused by lesions in the spine or at the hip joint. 

Osteopathic Prognosis 

Everyone is of the opinion that to forecast the probable result of a 
disease is one of the most difficult problems the physician has to meet. 
To state the duration, course, and termination of an attack of disease 
as presented by its nature and sjanptoms implies an accurate knowledge 
of both disease processes and changes, and an insight into the individual's 
idiosyncrasies backed by ripe clinical experience. And after each of 
these factors has been carefully considered to balance one against the 
other, nothing short of superhuman knowledge may present a sufficient 
insight in order to render an accurate prognosis. A prognosis represents 

1. Clark's Applied Anatom}', p. 331. 



The Practice of Osteopathy- 57 

the culmination of one's learning, an understanding of disease charac- 
teristics, and an insight into temperament. 

C. M. T. Hulett^ says : " Only when we can know all the conditions, 
causative and sequential, with their possible comphcations and termina- 
tions, together with a full history of therapeutic results in a large number 
of similar cases, and carefully analyzing and weighing these variotis ele- 
ments, are we prepared to really make a prognosis. " Nettie H. Bolles^ 
writes as follows: "The prognosis depends upon the cause of the disease, 
the possibility of removing the cause, or the hkehhood of recurrence of 
causes, and the chances of avoiding such recurrence. The circumstances 
to modify the outlook are various and deserve careful consideration." 
It is not the purpose here to go into the many essential details, for that 
would mean an outline and forecast of all disease processes, and the 
effect of numerous extenuating circumstances. The medical profession 
have been gathering data for these three thousand years and prognosis 
with them is still inaccurate and incomplete. Osteopathic science will 
add just so much to the accuracy of prognosis as the sum total of the 
knowledge displayed in the fields of osteopathic etiology, diagnosis, path- 
ology and therapeutics. Suffice it to give here a few salient practical 
hints as noted in the osteopathic treating room and at the bedside. 

Osteopathically it may be said that prognosis depends, first, upon 
the true conception of osteopathy; second, upon the relative value of all 
factors pertaining to health and disease; and, third, upon the skill (tech- 
nique and native ability) of the osteopath. The first and second being 
granted, the third includes a remarkably practical and pregnant field, for 
in no school does the physician get into as close touch and understanding 
of the actual condition of the patient's disorder as in the osteopathic. 
Although the fundamentals and principles of the osteopathic concep- 
tion of diseases are really broad, Hberal, and all-inclusive, still owing 
to the fact that each individual (and thus each disease) is more or less a 
law unto himself should there not be absolute tables and prescriptions to 
be governed b}^; remember, however, this does not imply our fundament- 
als are not basic or our principles are not truths, but rather the appHca- 
tion and execution of the same are as varied as the individual's consti- 
tution, temperament, and disease. Herein rests the really difficult 
practical consideration of etiology, pathology, diagnosis, treatment, and 
prognosis. In other words, if the diagnosis and treatment are accurate 
the result rests entirely with the patient. 

1. Prognosis — Journal of the American Osteopathic Association, Jan., 1906. 

2. Prognosis— Journal of the American Osteopathic Association, Nov., 1902. 



58 The Peactice of Osteopathy 

First, too much emphasis cannot be placed upon the fact that prog- 
nosis is dependent upon the osteopath — his education, training, abihty, 
experience, and technique. One's fitness is most important. And fitness 
and personahty complement each other. An osteopath may know 
theory and still not be practical; still one cannot be practical unless he 
knows theory. 

Second, osteopathic treatment frequently changes the usual course 
of acute disease. It is well known that many diseases have a certain 
regular course in their history. Many times the osteopath will be able 
to abort, lessen the severity, or cut short the ailment, thus changing the 
recognized symptoms and termination. 

Third, the knack of treatment, or knowing how to treat, not only 
one region of the body but all regions, not only one temperament but 
all temperaments. 

Fourth, the preparatory treatment before correcting the lesion. , 
Prevention, palliation, or cure, and thus prognosis, may be dependent 
upon a necessary preparatory treatment. Here is where a study of the 
patient's temperament is very essential. 

Fifth, a prolonged treatment may defeat one's purpose. As a rule 
a comparatively short, thoroughly indicated, specific treatment is best. 
Sixth, much, relative to prognosis, can be told by the tone of the 
vertebral ligaments. When a lesion corrects too easily or does not re- 
main well in place it shows a lack of tonicity on the part of the hgaments 
and muscles. Improvement is in direct ration to the increase of tonici- 
ty. 

Seventh, special care should be taken with the irritable spine. This 
spine commonly precedes the debilitated spine. Unless precaution is 
taken to apply inhibition before treating specifically a cure may be pre- 
vented or at least the disorder prolonged. 

Eighth, relaxation of muscles is not always essential, although the 
lack of it may prevent the correction of primary lesions. The relaxation 
should be carried out with care in order that all shock and irritation 
may be kept at a minimum. 

Ninth, needless stretching, traction, extending, rotation, and snap- 
ping of the neck is not only useless but may be positively dangerous. 
Rarely is it necessary to go through the above "movements" as many are 
accustomed to do. 

Tenth, it may be necessary, but not always, to give as additional 
treatment, after the anatomical defect has been specifically treated, a 
certain amount of stretching and moulding of the parts. 



The Practice of Osteopathy 59 

Eleventh, owing to the close personal relations of physician and pa- 
tient, personaHty has a powerful influence on prognosis. 

Twelfth, too much emphasis cannot be placed upon the uselessness 
and injurious effects of over and misapplied treatment. 

All of the above have a positive bearing on prognosis. The osteo- 
path should study his technique well. He will find that it gradually 
changes and improves from year to year. In a word, as he gains in ex- 
perience he will become more skiUful by giving careful attention to the 
development of the sense of touch, by noting the resistance of the tis- 
sues, and a score of details that are very hard to describe but the sum 
total of which determines and indicates the successful osteopath. 

Another practical point that bears upon prognosis as well as upon 
the health of the osteopath is the manner of giving treatment. First, 
the height of the treating table should correspond to the height of the 
.practitioner. The table should be made for the practitioner and not the 
practitioner fitted and warped according to a certain table. Second, 
give part of the treatments on a treating stool. Here there is greater 
freedom of movement on the part of the patient, hence greater and more 
effective leverage can be obtained. Suit your treatment to the patient, 
not your patient to the treatment. Third, make your weight count for 
energy expended in the treatment. As soon as one set of muscles be- 
come tired substitute another set, e. g., the back muscles and the arms, 
the arms and the hands. Fourth, whenever possible substitute the 
weight of the patient for expended energy. Fifth, when lifting keep 
the spinal column straight; do the bending of the body at the knees. 
Hence a better treatment and a more favorable prognosis, and besides 
that new occupation-neurosis, the "osteopathic back," will be mater- 
ially lessened in both severity and frequency. 



60 The Practice of Osteopathy 



OSTEOPATHIC TECHNIQUE 

The technique of treatment is, in a sense, a personal factor, for it is a 
well known fact no two osteopaths treat just alike. Nevertheless, the 
principles of technique are constant and universally appHcable, and he 
who apphes them with specificity manifest^ secures the best results, 
and exhibits a technique that is finished and characteristically osteo- 
pathic. General manipulations are not essentially osteopathic, although 
by employing them a few definite results may be obtained; still such 
technique should not be classed as distinctive osteopathic therap3^ Ev- 
ery case is a law unto itself and must be studied individually in order to 
be able to understand it perfectly. So much depends upon the abihty 
of the osteopath in the treating of a case, that in order to meet the indi- 
cations intelhgently he must have command of the various anatomical 
details of the body, not only in his mind but upon his finger tips.^ 

The sense of touch should be very acutely developed and this re- 
quires months of persistent, practical experience. A carefully educated 
sense of touch is the key-note to both osteopathic diagnosis and operative 
technique. From the very nature of the osteopathic conception — the 
physical body viewed as a mechanism whose disordered or diseased con- 
ditions demand anatomical readjustment — it is imperative that a deh- 
cate and educated sense of touch be acquired in order to logically and suc- 
cessfully appty its tenets. Proficiency means not only being able to 
note certain small physical irregularities, and various degrees and areas 
of muscular contractions, and variations in body temperature, but the 
extent and state of vital resistance, that is, tissue condition, and the 
teehng of organic resistance, e. g., the heart, lungs, liver. These 
are the special features wherein osteopathic fingers detect disease causes 
and traces. To know the difference between normal and abnormal 
structural deviations and distortions, as well as organic changes, re- 
quires an accurate, detailed knowledge of anatomy and pathology with 
a. systematic daih^ education of the sense of touch; but to realize, ap- 
preciate and know by tissue resistance feehng that nutritional condition 
is improving requires much more practical experience. 

Thus two very practical points should be taught to and thoroughly 
impressed upon every osteopathic student : First, the sense of resist- 
ance of the tissues. This gives us an absolute clue to the vitahty of 
the patient. As has been stated, there is a vast difference between the 

1. See Ashmore's Osteopathic Mechanics. 



The Practice of Osteopathy 61 

feel, the sense of resistance, of normal and abnormal tissues; for instance,, 
a normal muscle and a contractured muscle, a normal liver and a con- 
gested liver, a normal intestine and a prolapsed intestine and these dif- 
ferences comprise innumerable gradations. 

Second, the receptivity of the patient to treatment. This 
is dependent upon the vitality of the tissues. The sense of resistance 
to touch gives us an important diagnostic clue; the receptivity of the 
patient to treatment tells us much as to prognosis. After a few treat- 
ments the receptiveness will be positive or negative; that is, the patient 
is, or is not, responding to treatment. Consequently the receptivity of 
the patient usualty tells much as to the state of nutrition. 

Definite principles should be followed when applying the technique, 
for the osteopathic lesion is a "structural perversion," thus indicating, 
mechanical readjustment for its correction. The time is coming when 
the technique will be taught graphically and mathematically. This 
would not be a difficult thing to do, and it could not but prove inval- 
uable aid to the student. He can then the more readily and compre- 
hensively grasp the principles involved. To resolve and illustrate ma- 
nipulative readjustment to and by the principles of mechanics would 
add considerable to osteopathic development. For example, how nicely 
the correction of certain innominata maladjustments illustrates the prin- 
ciple of the wheel and axle. Vertebral and rib displacements when re- 
adjusted make appUcation of the principles of the simple machines. 
We are gradually approaching a more comprehensive understanding of 
the physiologic movements of the spine and of the etiologic role of muscle 
tension. This is part of the foundation work. Great care must be 
exercised in correlating this data with the individual case, for in therapy 
we are dealing with abnormahties — not alone normal physiologic chang- 
es. If our distinctive dynamics and therapeutics were taught in this 
manner the average osteopath would be more specific and comprehensive 
in his work and as a consequence more scientific. And consequently the 
principles involved in each and every case would stand out clearlj-. 
Hence diagnosis would be more exact, routine pommeling discarded, 
and better all around technique executed. 

Two general rules are apphcable to all dislocations, whether partial 
or complete: 1. Exaggerate or increase the dislocation. This is to 
relax the tissues about the dislocated articulation and to disengage the 
articular points that have become locked. 2. Reduce the dislocation 
by retracing the path along which the parts were dislocated. Hence 
to correct a lesion, for example, a vertebral lesion: (1) Exaggerate the 



62 The Practice of Osteopathy 

lesion. (2) Place the fingers of the hand that are not employed in exag- 
gerating the lesion over the extended portion of the lesion. (3) Extend 
the region that is flexed when the lesion was exaggerated. (4) When 
the lesion is being extended produce traction and slight rotation of the 
region. (5) At the same time extension, traction and rotation is being 
produced push in upon the extended portion of the lesion. To this might 
be added for sake of clearness and greater assurance of success: (a) 
Be positive the focal point absolutely corresponds to the lesion, or else 
most if not all of your effort will be useless, (b) Just before reaching 
the maximum of exaggeration have your fingers correct^ placed for the 
readjustment, and at the very morfient of maximum exaggeration or 
just a fraction of a second prior begin to correct or readjust, or else you 
will lose the vantage gained and the operation will probably be a failure. 
(c) The general traction and rotation are to aid in unlocking the lesion, 
not to readjust as some may think. Inhibiting and releasing the soft 
tissues, such as spasms, contractions and contractures of muscles, and 
stretching thickened and adherent ligaments is very important prehm- 
inary work. Then, next to securing exact leverages an essential point 
is to maintain the release or exaggeration until the readjusting step is 
incepted. In other words, coordination of all factors is the desideratum. 
The lack of this is the cause of many failures. Hot fomentations fre- 
quently assist in relaxing irritable and spastic soft tissues. This, how- 
ever, is but a preliminary measure. AU rough handling, needless snap- 
ping of parts, and excessive rotation and stretching are not only apt to 
tighten the lesion more, shock the system and irritate the parts, but it 
may be absolutely dangerous. 

It should not be forgotten that the osteopath includes many meas- 
ures in his treatment of various diseases, as nursing, dieting, hygiene, 
sanitation, hydrotherapy, antidotes, antiseptics, etc., and does not de- 
pend upon readjustive manipulation alone, although correcting disor- 
dered anatomical structures and perversions are paramount in the treat- 
ment. 

The General Treatment. — A general treatment but accentuates 
the ignorance, in a majority of cases, of many so termed osteopaths. 
It is a deplorable fact that there is a tendency among some osteopaths to 
give general treatments in every case presented. The only explana- 
tion of such a procedure that one can think of is a lack of conception as 
to what osteopathy really is. To give a general treatment in every case 
is not only actually detrimental to the patient but it is the height of folly 
on the osteopath's part, for it gets him into a slovenly habit of procedure 



The Practice of Osteopathy 63 

from both scientific and curative points of view, besides giving the out- 
side world an impression that osteopathy is but little different from mas- 
sage and Swedish movements instead of skillful, mechanical engineer- 
ing of the human body. But a "general treatment" is not to be con- 
fused with definite attention to be a series of more or less interrelated 
lesions. The essential point is to normahze the body when and where 
distinctly indicated and after a skillful manner. 

A general treatment, broadly speaking, should be given only under 
three conditions: (1) Constitutional diseases that are to be treated 
S5'Tiiptomatically. (2) Certain anemic cases. (3) When one is ignorant 
of the real cause of the disease. Each of these conditions is self-evident 
why a general treatment should be given. A fourth might be added, 
for those individuals who think they are not getting value received unless 
they are treated from head to foot. Such patients are usually ignorant 
of the philosophy of osteopathy and it is the osteopath's duty to teach 
them differently. 

The general treatment consists in stretching the spinal column from 
the atlas to the coccyx and relaxing all contracted muscles along both 
sides of the spinal column, besides giving special treatment to the cervical 
region, between the scapulae, the splanchnics and internal and external 
rotation of the legs. It is no wonder that fake osteopaths do cure a case 
occasionally. They are quite certain to correct some disorder by pulling 
and hauling a patient around in such a manner. Still on the other hand 
they are very likely to do injury to the patient. Those who claim that 
no injury can come from osteopathic treatment are mistaken. One can 
injure a person by treatment if he is not careful. It does not stand to 
reason that the most dehcately constructed mechanism should stand 
any amount of manipulation and misdirected force that may be given it. 

Positions of the Patient and Physician in Treating. — The 
position of the patient when a treatment is given depends altogether 
upon the affection to be treated. Probably about one-half of the cases 
can be treated to advantage upon a table, the remainder sitting on a 
stool. Many osteopaths treat nearly all their patients upon a table. 
It is much better to change back and forth, because to correct a certain 
disorder may be hard upon the table, but will be comparatively easy 
when the patient is on a stool, and vice versa. Besides, constantly chang- 
ing back and forth rests a physician greatly. 

Learn to treat in various positions, because it will be impossible 
to have all cases assume a certain position when being treated; and es- 
pecially in treating acute cases one is obliged to suit his treatment to 



64 The Pkactice of Osteopathy 

the patient and not the patient to the treatment. There is also a ten- 
dency- for one to get into slovenly habits of treating when patients are 
all placed practically in one position, and certainly one cannot treat all 
cases in one position to equal advantage. Also learn to treat as well 
with one hand as the other. Many times one will be in such positions 
that equal use of either hand will be required. Carefully educate the 
sense of touch in both hands. 

Another point should receive consideration: learn to shift the 
strength exerted in treating from one set of muscles to others. For ex- 
ample, when one is standing for a long time he will continually shift his 
weight from one limb to the other. In the same manner in treating 
use the strength of the hands awhile, then the arms, then the muscles of 
the back, then the weight of the body, etc.; all in such a manner that 
there is a constant change by utilizing certain groups of muscles for the 
same work, as well as utiHzing the weight of the body of both physician 
and patient to advantage. It rests a physician greatly and thus allows 
him to perform a maximum amount of work with a minimum amount 
of strength and labor. 

It is frequently an advantage to the physician to treat upon the 
nude skin, thus preventing the fingers from becoming tender. Gowns 
can be easily made that open down the back so that the patient does 
not have to disrobe. 

The Neck and Head. — In the treatment of the neck the patient 
may assume the sitting posture or lie flat upon the back. The latter 
is preferable, as then one has complete control of the neck and head. 
Absolute control of a part is always necessary and when this is secured 
the dangers are reduced to a minimum, provided always that reasonable 
discretion as to the amount of strength, is used. Before correcting the 
various deviations of the cervical vertebrae it is usually best to thor- 
oughh" relax all the muscles, superficial and deep, about the field of op- 
eration. In relaxing muscles three methods may be employed. The 
muscle may be firmly grasped and manipulated until relaxed, or a firm 
pressure may be exerted upon the muscle and thus inhibit its nerve force 
until the muscle relaxes, or the muscle may be longitudinally stretched. 
The second method is comparatively slow and is usually given in acute 
cases where the patients are so weak and exhausted that they cannot 
stand any severe manipulation. This method, however, has certain 
advantages whan employed as a preparatory^ step in interosseous adjust- 
ments, though steady traction accompanied with slight rotation, if pre- 
cisely locaKzed, has many advocates. 



The Practice op Osteopathy 65 

In relaxing muscles by manipulation, grasp firmly the belly of the 
muscle and draw outward on the muscle several times until it relaxes. 
If the patient is sitting, place one hand upon the head of the patient or 
about the chin in such a manner that complete control of the head is 
maintained throughout the procedure; then with the fingers of the other 
hand upon the contracted muscular fibres a manipulating or kneading 
of the muscle can be given. It is best to flex the neck and head to the 
side where the contracted muscles are, so that a better hold of the mus- 
cle may be maintained; then by a series of flexions and extensions with 
manipulation of the contracted muscles outward, results can be readily 
obtained. When the patient is lying on the back the physician may 
stand to one side of the patient's head and with one hand on the fore- 
head of the patient and the other hand around the opposite side of the 
neck, a rotary motion of the head and neck, which is equal to flexion and 
extension in the sitting posture, may be given by the hand on the frontal 
region while the other hand relaxes the muscles; or the osteopath may 
stand at the head of the patient and with either hand on the side of the 
head and neck of the patient a series of rotary movements of the head 
and neck may be given with manipulation of first one side of the neck 
and then the other; the hands and fingers being placed in such a manner 
that when the fingers of one hand are relaxing the muscles on its side 
the other hand is executing the movements of the head and neck, each 
hand continually alternating in the work. This latter method requires 
some practice in order to do the work readily and successfully, for quite 
a variety of movements are required. 

In the former method after one has worked on one side he is obliged 
to change to the other side and go through the same process. Move- 
ments may also be given to stretch the contracted muscles, thus over- 
coming the contraction and producing relaxation of the muscles. 

After having relaxed the muscles over the field of operation, correct- 
ing the vertebrse will generally be easier to accomplish. In readjusting 
an atlas it matters but little whether the patient is sitting up or lying 
down. A firm hold of the atlas can be gotten in either instance. In 
correcting the middle and lower cervical vertebrse it is best to place the 
patient upon the back. 

In correcting dislocations, as heretofore suggested, two general rules 
should be followed: (1) Exaggerate or increase the dislocation. This 
is to relax the tissues about the dislocated articulation and to disengage 
the articular points that have become locked. (2) Reduce the lesion by 
retracing the path along which the parts were dislocated. One can readi- 



66 The Practice of Osteopathy 

ly see that a dislocated ball and socket joint could be reduced only by the 
dislocated bone retracing the path by which it left its socket, for the 
capsular Ugament would at once prevent its returning to the socket 
by any path other than that taken when dislocated. This applies to all 
dislocations to a greater or less extent. 

After locating the exact position of the abnormal vertebra the first 
rule is applied, i. e., exaggerating the lesion by flexing the head in the 
opposite direction to which the vertebra is dislocated. Then with one 
or two fingers placed firmty upon the side of the vertebra in the direction 
dislocated, so that when the proper time comes the vertebra may be 
pushed or slightly rotated back into its normal position, with the other 
hand produce flexion of the neck, so that the angle of flexion is exactly 
over the involved vertebra; next produce slight traction, so as to be sure 
that the articular points will be disengaged; and then with rotation and 
extension of the head to a normal or upright posture, at the same time 
pushing in on the disordered vertebra, are the movements to be executed 
in reducing a dislocated vertebra. It takes considerable practice to 
be able to correct a vertebra and to know when it is corrected. The 
amount of force appUed varies greatly in different cases. Cases of re- 
cent subdislocation require but Httle force unless there is marked spas- 
ticity of tissue, while in long standing cases many times the amount of 
force required is about all that one wishes to exert. As a rule in many 
chronic cases it is better to give a series of preparatory treatments in 
order to reduce muscle fibrosis and thickening of capsular hgament. 
Remember that often it is a sHght rotary movement or twist given that 
aids the most in executing rule second. No matter to what position a 
vertebra is rotated or side-bent the principles applied are the same in 
each case. 

Be very careful when flexing, extending or rotating the neck that too 
much strain is not brought to bear upon the ligaments. Some osteo- 
paths seem to take dehght in rotating and flexing the neck to a great 
degree. It is a dangerous procedure and moreover does not accomplish 
anything in particular. It should be kept in mind that osteopathic 
treatment is scientific and not a number of general movements of various 
regions of the body. Locate the lesions exactly and then a specific treat- 
ment can be given in every instance. To illustrate the treatment accord- 
ing to the preceding rules we wiU assume that a certain cervical verte- 
bra is anterior, say the fourth cervical. This means that there is an 
interosseous lesion between the fourth and fifth. The inferior articular 
processes and facets of the fourth have slipped upward and forward on 



The Practice of Osteopathy 67 

the opposing facets of the fifth. First, hyper-extend the head in such 
a manner that the fulcrum comes exactly over the displaced articulating 
planes, thus throwing the fourth vertebra still more anterior, or in other 
words, exaggerating the lesion or increasing the space anteriorly between 
the fourth and fifth cervicals, so that when the head is flexed forward 
and pressure is exerted upon the anterior part of the vertebra (body or 
transverse process) the vertebra will have room and release enough to 
occupy its normal position. Second, when the head is hyper-extended 
place a finger anterior to the transverse process of the dislocated verte- 
bra and with the other hand around the head, that is producing the hyper- 
extension, throw the head forward with slight traction and rotation and 
at the same time push posteriorly quite strongly upon the dislocated 
vertebra. Follow out the same principles in all cases, no matter in which 
way the vertebrae are deranged. 

There are several methods of applying the underlying principles 
of adjustment. Relaxation and leverages may be secured in various 
ways. Preciseness, expeditiousness and skilKulness can be attained only 
by considerable personal experience. 

In cases where the lesion is between the skull and atlas have the pa- 
tient sit on a stool with the back part of his head against your chest, 
and reach around the head with one hand under the chin; then with the 
other hand around the transverse processes of three or four upper cervical 
vertebrae pull the spinal column toward the median line, while at the 
same time hfting up on the skull with the other hand and throwing the 
skull toward the median line. The object of lifting up on the skull is 
to relax and disengage the articulations, by inhibition, traction and ro- 
tation, between the occipital bone and atlas. This is one method ap- 
plicable to the various lesions of the occiput, which are of frequent 
occurrence. 

In treating the pharynx, tonsils and larynx, outside of correcting 
spinal lesions, an anterior treatment to these organs is very effective. 
Examine the deep muscles beneath the angle of the jaw when the pharynx 
and tonsils are involved ; and when the larynx is affected note the condi- 
tion of the muscles on either side of the larynx. After locating deeply 
seated contracted muscles in the region of the angle of the inferior max- 
illa place the fingers over the contracted tissues, and then by a down- 
ward, inward sweeping motion toward the median line the muscles may 
be readily relaxed. When treating the larynx relax the tissues on both 
sides by an upward, inward movement. These treatments are very 
effectual when apphed directly to the disordered tissues. 



68 The Practice of Osteopathy 

Attention should also be given to the lymphatics. In simple in- 
fections treat the glands very hghtly but attempt to break down the 
surrounding edematous barrier. Release all the tissues down to and 
including clavicles, first ribs and pectoral and axillary regions. 

To treat slight lesions of the inferior maxillary articulation, stand 
at the head of the patient when he is lying down and hook the fingers 
about the jaw just in front of the angles, and with the thumbs over the 
bridge of the nose have the patient open the mouth while considerable 
force is exerted against his effort. This reduces any sUght dislocation of 
the inferior maxilla. When the jaw is completely dislocated place a 
piece of wood or hard substance between the molars and exert pressure 
upward and backward on the chin. If the dislocation is bilateral work 
on one side at a time. 

The object of treatment to the face is to stimulate or inhibit points 
of the fifth nerve that come near the surface (see neuralgia of fifth nerve) . 
While the patient is lying flat upon the back carefully stimulate these 
various points, especially the supra-orbital and nasal, with a downward 
and outward movement, or inhibit as indicated. 

In treating the scalp relax the muscles over the scalp thoroughly. 
This is secondary treatment to correcting the innervation to the scalp 
at the upper four or five cervical vertebrae. 

In cases of pharyngitis, tonsilUtis, croup, hay fever, etc., an effective 
local treatment may be given through the mouth upon the soft and hard 
palate. Introducing a finger into the mouth clear back upon the roof 
of the soft palate, and with a downward and backward sweeping move- 
ment from the median line on either side toward the tonsils, considerable 
relief can be given the patient. This treatment relaxes the tissues, re- 
Heves the congestion, and gives a stimulating treatment to the local 
nerves. A treatment of the same nature may be given over the hard 
palate to affect the palatine nerves, especially in hay fever, when the 
itching of the palate and sneezing are extreme. In cases of young chil- 
dren it is best to protect the finger by wrapping a piece of cloth around it. 

An osteopath should never give a manipulation or movement unless 
he understands wh3\ Just as soon as one gives general imitating move- 
ments, from that moment his work is not that of a scientific osteopath, but 
of a Swedish movement curist and masseur and a poor one at that. The 
osteopath's work is to locate the anatomical derangement and correct 
it, as a mechanic would adjust any disordered mechanism. General 
treatment amounts largely to naught, although in some few instances it 
is of benefit. 



The Practice of Osteopathy 69 

To give a detailed description of the treatment of all lesions that 
may be found in the cervical vertebrae would be impossible in this sketch ; 
only a general survey of the work can be given. Each case calls for 
special treatment, but the same general principles are applicable in each 
case. If there is any one thing that should be ehminated from osteo- 
pathic treatment it is those mechanical routine movements of rotating, 
flexing, extending, and various Swedish-movement-massage-like manip- 
ulations that certain osteopaths give in each and every case. It shows 
that they are imitators and do not have a correct conception of osteo- 
pathic therapeutics. True it is, that routine movements will have stim- 
ulating and other effects upon the system. But does the body require 
such treatment? Is it lack of exercise on the part of the patient? If it 
is, then let the patient exercise himself. You do not want to lower your- 
seK to be a mere "engine wiper," or an exerciser. If it is not the lack 
of exercise and the system is in need of certain treatment, then seek the 
cause and apply a specific treatment. Do not hide behind generaUties. 

The Ribs. — In correcting dislocated ribs many methods may be 
employed, but all are subject to the same principles as given under the 
treatment of the neck and head. 

One of the best methods to correct typical ribs is to have the patient 
upon the side with the side of the affected ribs upward. Find out ex- 
actly the nature of the dislocation, i. e., what is the relation of the dis- 
located rib to the other tissues. Note whether the rib is upward, down- 
ward, inward or forward, locate exactly the dislocated rib. Then, while 
standing back of the patient, place your fingers upon both ends of the 
rib. Place your fingers in such a manner that when the proper time in 
the procedure arrives, all that will be necessary will be to push the ends 
of the rib into their articulations. For instance, if the rib is raised anter- 
iorly and lowered posteriorly, you will place the fingers on the sternal 
end, above the affected rib and the fingers on the vertebral end, below 
the rib, so that when the rib has been released from its abnormal position 
it may be slipped into normal position. After having placed the fingers 
in the exact position necessary, have an assistant take the arm and draw 
it obliquely across the face, while at the same time the patient takes a 
forced inhal'ation. The object of drawing the arm across the face and 
the deep inhalation is to exaggerate the lesion — to draw the ribs out of 
their locked position — so that the fingers upon either end of the rib may 
push the rib into normal position. Drawing upon the arm raises all 
the upper ribs as well as the dislocated typical rib, principally by the use 
of the serratus magnus; also inhalation has an effect to throw the rib out- 



70 The Practice of Osteopathy 

ward and upward and thus away from its articulation. Thus after the 
lesion has been increased sufficiently to loosen the rib from its abnormal 
position, the arm is relaxed, the patient exhales, and the fingers upon the 
ends of the rib correct the dislocation. This treatment is used to the 
greatest advantage when there is a dislocation of a typical rib; it can be 
given while the patient is lying down or sitting up, although the former 
position is preferable. 

An excellent method, when the sternal end of the rib is dislocated 
is to have the patient sit upon a stool with his back toward the physi- 
cian; then by placing the knee in the back (while standing up, or easier 
still for the physician to sit upon an operating table back of the patient) 
over the vertebral end of the rib so that the rib may be held rigid poster- 
iorly, reach around with one hand over the dislocated end of the rib and 
place the fingers upon the rib in the direction dislocated ; so that when the 
rib is sufficiently released from its abnormal position it can be readily 
pushed into place; then with the other hand under the axilla of the arm 
on the affected side, pull up and back on the shoulder, so that the rib 
may be pulled away from its sternal articulation; and at the same time 
have the patient take a deep inhalation so as to aid in throwing the rib 
outward, upward and away from its sternal attachment; then when the 
end of the rib has been released sufficiently, relax the hold underneath 
the axilla, have the patient exhale, and sUp the rib into its normal posi- 
tion by the fuigers over the end of the rib. This is an excellent method. 
It is easy to give and does the work admirabh^ 

Practically the same procedure may be gone through when the 
vertebral end is dislocated, by changing 3'our position to the front of 
the patient, but there is danger- of the knee slipping off from the sternum 
during the operation and injuring the ribs. Several other treatments 
may be given to correct dislocations of the vertebral ends of the ribs. 
For example, while the patient remains sitting the osteopath stands in 
front of the patient and reaches around both sides upon the angle of the 
ribs; then with an outward and upw^ard movement of the fingers upon 
the angle of the ribs, they are pulled away from their locked position and 
allowed to slip into normal articulation. This treatment is applicable 
onl}' when the ribs are dislocated downward, but it is one of the best 
treatments for such cases. 

Another method oftentimes emploj^ed in correcting dislocations of 
the vertebral end of the ribs is to have the patient lie flat upon the side 
with the affected side upward; then b}^ flexing the arm on the forearm 
and placing the elbow against the chest or abdomen reach over the pa- 



The Peactice of Osteopathy 71 

tient upon the angle of the dislocated rib and pull it away from the ver- 
tebra; when it is pulled away from the spinal column sufficiently, push 
upward or downward on the angle of the ribs, as the case may demand. 
The elbow placed against you gives complete control of the patient and 
aids, by your weight, in throwing the rib upward or downward. 

A treatment somewhat like the preceding one which is commonly 
employed, is to reach underneath the patient's upper arm, when he is 
lying upon his side, with the arm extended upward across the face; then 
by placing the fingers of the hand underneath the patient's arm over the 
angles of the affected rib or ribs and reinforcing the hand by the fingers 
of the other hand an upward, outward and rotary movement can be given 
the ribs, which pulls them out of their abnormal position and allows them 
to return to their normal articulations. 

An effectual treatment fco spread and raise the upper ribs is to have 
the patient flat upon the back, and with the fingers of one hand under- 
neath the angles of the ribs and the other hand upon the elbow of the 
patient's arm of the same side throw the patient's arm across the chest 
transversely and bear down upon the elbow, at the same time spring 
upward and outward on the angles of the ribs with the other hand. By 
throwing the arm across the chest and bearing down upon the elbow a 
strong leverage can be obtained upon the upper ribs, especially those 
between the scapulae. This treatment is very efficacious in certain 
lung and heart diseases. 

Still another method of adjxistfng ribs is to have the patient flat on 
his face upon an operating table with the arms hanging down on both 
sides of the table and a small pillow or folded blanket beneath the upper 
part of the chest; then standing beside the table, or better still, with 
one foot upon a low stool and the knee of the other limb upon the table 
in such a manner that one is directly over the patient's dorsal region 
one is then in a position to have full control of the vertebral end of the 
ribs. If the ends of the ribs are displaced downward, placing the thumbs 
over the angles of the ribs and pushing upward and outward on the angles, 
the ribs can be very readily crowded into position. If the ribs, especially 
between the scapulae, are dislocated in any direction, they may be quite 
readily corrected by placing the hand over the shoulder posteriorly and 
throwing it outward and upward and away from the spinal column in 
such a manner that the ribs are pulled away from the abnormal position; 
then upon relaxing the hold upon the shoulder with the one hand, the 
fingers of the unemployed hand may push upward or downward, as the 
occasion requires, on the angles of the affected side so that the ribs may 
be slipped into place. 



72 The Practice of Osteopathy 

Many times one is obliged to treat the ribs of one side as a whole. 
In such instances the ribs are almost invariably thrown downward ex- 
cept on one side of scoliosis of the dorsal region. Several methods may 
be employed to raise the ribs. Probably the best method is to have the 
patient upon the side and with one hand upon the angles of the ribs and 
the other hand holding the wrist of the upper arm of the patient, an up- 
ward lifting movement is given both upon the angles of the ribs and upon 
the arm of the patient while the patient inhales. The work upon the 
angles of the ribs is to raise the ribs directly; the work upon the arm is to 
raise the ribs indLrectly, principally by the use of the serratus magnus. 
Another effective treatment is to have the patient upon the back and with 
one hand over the antsrior ends of the ribs and the other hand over the 
angles of the ribs an upward movement is given them by springing the 
ends of the ribs toward each other and by strong inhalation on the part 
of the patient. This treatment is most effective where the false ribs are 
at fault and especially in case of hemiplegia. While the patient is upon 
the back an assistant may take hold of the arm and draw it upward oxer 
the head of the patient, producing considerable additional upward ten- 
dency of the ribs, and the physician giving the same treatment of the 
ends of the ribs as before; or the physician may take an arm in one hand 
and raise it above the head of the patient and with liis other hand around 
the angles of the ribs, and the patient inhaling deeply, the ribs maj'^ be 
raised. 

A treatment used a great deal in raising the ribs as a whole is to have 
the patient sit upon a stool, and reaching around the patient from the 
front, place the fingers upon the angles of the ribs and raise them upward 
on both sides at the same time. This treatment can also be given by 
standing behind the patient and reaching around upon the anterior ends 
of the ribs and lifting upward while the patient aids you by deep inhala- 
tion. Remember that many times the ribs are drawn downward b}' con- 
traction of the muscles, due to atmospherical changes and slumped pos- 
tures. One should begin at the upper ribs in all treatments where the 
ribs are to be raised, as a whole, and work downward. 

To correct the first and the floating ribs a different treatment has 
to be given than the foregoing. 

An upward displacement is the most common lesion of the first 
rib. To correct such a dislocation, have the patient sit upon a stool 
and with one hand pull the head to the opposite side in order that the 
lesion may be exaggerated by traction of the lateral muscles of the neck 
(principally the scaleni) upon the rib; this disengages the rib from its 



The Practice of Osteopathy 73 

abnormal position; then with the fingers of the other hand upon a point 
midway of the ends of the rib, exert a downward pressure at the mo- 
ment the extended head is relaxed describing a short are. But don't 
relax head until readjusting pressure is exerted upon rib. If the patient 
is unable to sit up, and it is not best to give the foregoing treatment, 
have the patient flat upon the back, with one hand take hold of the arm 
on the affected side and pull down and out upon the shoulder so that the 
rib may be somewhat drawn away from its articulation and released from 
its position; then with the fingers of the other hand upon the center of the 
rib, or its highest point, press downward when the hold upon the arm 
is being relaxed. Correction of an upper displacement of the first rib is 
an every day occurrence. Downward dislocation of the ftrst rib, is 
rare. To reduce this dislocation, place the thumb beneath the vertebral 
end of the rib, and with the other hand lift up strongly on the shoulder 
from beneath the axilla, at the same time exerting pressure upward with 
the thumb on the end of the rib. 

The floating ribs may be dislocated obliquely downward, or the 
free end of the rib may be caught underneath the end of the rib above. 
In either case, in order to correct the displacement, place the patient 
upon the back with the thigh on the affected side flexed upon the abdo- 
men so that the tissues about the field of operation are relaxed; then 
bear down carefully but firmly over the free end of the rib with the fingers 
until one finger can be hooked underneath the end of the rib; then with 
the other hand over the vertebral end of the rib, have the patient take a 
deep breath, at the same time springing the ends of the rib toward each 
other, thus relaxing the rib from its locked position; then have the pa- 
tient exhale quickly and at the same time spring the rib into its normal 
position. It oftentimes requires repeated trials, especially in stout per- 
sons, and quite often the operation is painful to the patient. It is neces- 
sary that one should understand this operation thoroughly, as it is one of 
the most common treatments in osteopathic practice. The floating ribs 
are very hable to dislocations and may be the cause of many pains in 
the side, disturbances of the vessels as they pass through the diaphragm 
and inflammation in the ihac region. A palliative treatment may be 
given the floating ribs by having the patient he flat either on the back or 
on the side; then place the hand near the vertebral end of the ribs and 
raise them upward while the patient takes a deep bi-eath. 

Treatment of lesions between the manubrium and gladiolus 
are best given by placing the patient with the face downward upon the 
operating table, and having the articulation of the manubrium and 



74 The Practice of Osteopathy 

gladiolus just over the edge of the table. An assistant should hold the 
patient firmly upon the table while hyper-extension or flexion, as the 
case may require, with traction, is exerted upon the head, neck and 
shoulders, and manipulation of the articular points is given to reduce 
the dislocation. The same principles are emploj^ed here as in correcting 
lesions elsewhere. 

Correction of the cartilages along the sternum is very easily 
accompHshed by having the patient sit upon a stool and the osteopath 
standing behind the patient places a knee in the back; then reaching 
around with one hand over the cartilages and the other hand underneath 
the axilla, execute the same movement as given in correcting disloca- 
tions of the sternal ends of the ribs. 

A treatment sometimes used to release a depressed condition of the 
cartilages of the false ribs is to stand behind the patient while he site 
upon a stool and reach around him with fingers underneath the cartilages 
and raise them upward as he inhales. By having the patient take a deep 
breath and then exhale quickly while the fingers are over the cartilages 
a much better grasp of them can be obtained. This treatment should 
be carefully given, as there is danger of tearing the cartilages loose from 
the ribs. 

The Dorsal and Lumbar Spinal Regions. — Here, as in other 
regions of the body, before an attempt is made to correct the vertebrse 
the muscles should be thoroughly relaxed. One of the easiest methods 
to relax the muscles is to have the patient He upon the side, and then by 
standing in front of the patient and reaching over him with the finger? 
upon the contracted muscles an upward and outward rotary manipula- 
tion is given; or the patient may sit upon a stool while the physician 
stands in front with the arms around the patient and the fingers over the 
contracted muscles manipulating them upward and outward. Another 
ver}^ easy method is to stand behind the patient while he sits upon a stool 
and place a thumb over the contracted fibres, with the other hand under- 
neath the axilla lifting the shoulder upward and backward so as to favor 
a relaxation of the muscles, while the thumb manipulates them. 

In relaxing the muscles of the lumbar region have the patient 
on the side upon the table; then flex the thighs upon the abdomen with 
your weight against the knees so as to control all movements of the pa- 
tient ; reach over the patient with the fingers upon the contracted tissues 
and manipulate them outward and upward on either side until they are 
relaxed. A method sometimes employed to relax the muscles of the 
dorsal, lumbar and sacral regions is to place the patient flat on his face 



The Practice of Osteopathy 75 

upon the table ; then by pushing up on the muscles from above downward 
with the flat of the hand they are easily relaxed. This treatment should 
be especially given when the patient's muscles are contracted by atmos- 
pherical changes and from standing in one position for a long time. When 
the muscles of the back are contracting they draw downward and many 
times draw the ribs with them, as well as tensing the tissues over the 
sacral foramina and obstructing or irritating the sacral nerves. By using 
the modern table longitudinally relaxing, or stretching, the lumbar and 
dorsal musculature saves considerable strength and effort of the physi- 
cian. 

To correct vertebral lesions of the dorsal region the same rules 
should be followed as in treating lesions of the cervical vertebrae. Treat- 
ments may be given with almost equal ease whether the patient is lying 
on the side or sitting up. 

To illustrate the treatment of the dorsal region when the patient 
is lying down, assume that there exists a lateral lesion, combined rotation 
and sidebending, between two vertebrae ; if the lesion is below the seventh 
dorsal use the legs as a lever, and if the lesion is above the seventh dorsal 
use the head and neck as the lever. Have the patient lie upon the side 
toward which the lesion is pronounced, either reach under the neck or 
around the limbs with one hand, and with the other hand upon the lesion 
bend the head and neck or the thighs in such a manner that the angle of 
the flexion is directly over the break in the spinal column; this is to ex- 
aggerate the lesion; then by lightly lifting up on the neck or limbs and 
with a sHght rotation of this lever the flexed parts should be extended, 
at the same time exerting pressure with the hand over the lesion in such a 
manner that the vertebra is pushed forward toward its normal position. , 

Practically, the same treatment is given when a patient is sitting 
up, with the exception, of course, that the hmbs cannot be used as levers. 
Lesions of the dorsal region or even the lumbar region can be corrected 
while the patient is sitting up. By this method considerable lifting is 
done away with. In fact, the weight of the patient can be used to great 
advantage by substituting it for one's strength. No matter in what 
direction the lesion is, the physician reaches around the patient's shoul- 
ders so that he just holds the weight of the patient from falhng to one 
side or the other; thus with one hand manipulating the lesion the other 
arm is around the patient guiding the weight of the body in flexion, rota- 
tion and extension. It is not always necessary to lift up on the patient 
but just let the weight of the patient act as strength applied to the power 
arm. Always make it a point when working upon dislocated vertebrase 



76 The Practice of Osteopathy 

in any region that just as soon as one has obtained a sUght movement in 
the lesion do not attempt to correct it any more for the time being. 
A sUght movement toward the right direction may be all that is neces- 
sary to relieve the ill effects of the lesion. In fact it might be impossible 
to get the lesion anatomically correct as the shape of the vertebra may 
have conformed in a greater or less extent to its abnormal position. 

An excellent method to correct the various combinations of rota- 
tion and sidebending of the third to ninth dorsals is to have the patient 
sit up with the physician either sitting or standing, depending upon height 
of seat, back of the patient. Have the patient lean back until head is 
supported upon shoulder of physician, and the anterior and posterior mus- 
culature of torso, abdomen and pelvis are thoroughly relaxed. Reach 
around the patient's chest with one arm, the hand of which is placed 
beneath the axilla. The thenar eminence of the other hand is placed 
upon the posteriorly prominent transverse process of the lesioned seg- 
ment. Then with careful hyperextension, traction, and rotation and. 
sidebending of the torso, the anchorage is released, care being taken 
that localization is exact; this moment of coordination is accom- 
panied with a thrust of the thenar eminence upon the transverse pro- 
cess. Relaxation, leverages and thrust must be precise and thoroughly 
coordinated. 

To reduce vertebrae that are deviated anteriorly in the dorsal 
region, especially between the scapulae, is often a hard matter. A 
satisfactory method is to stand behind the patient, while he is sitting 
upon a stool, and reach around both sides of him upon the sternal ends of 
the ribs corresponding to the anterior vertebrae; then have the patient 
relax with the head upon the chest, and at the same time take a full 
inhalation while pressm-e is exerted posteriorly upon the sternal ends of 
the ribs. The object of this method is to pull back the rigid ribs (the 
lungs being filled with air) which are attached to the anterior surfaces 
of the transverse processes of the vertebrae, and thus upon the anterior 
vertebrae pushing them posteriorly; all of the muscles of the body being 
quite passive and the head rela^^ed on the body, a separation of the verte- 
brae is accomplished, thus favoring a crow^ling posteriorly of the sub-dis- 
locatecl vertebrae. 

To correct vertebrae of the lumbar region is on the whole much 
easier than in the dorsal region. Here the legs can be used as levers 
to great advantage. By the same method of flexion, rotation, and ex- 
tension, as employed in the dorsal region when the patient is lying on 
the side, the result can generally be obtained. 



The Practice of Osteopathy 77 

Sidebending is the most common single lesion of the lumbar ver- 
tebrae, though there may be some rotation at the lumbo-sacral juncture. 
Occasionally malformation is found at the fifth. To correct the lum- 
bar lesions the following method is often used: place the patient upon 
the side of the rotation or sidebending with knees flexed, buttocks well 
back and entire spinal column straight. Next bring torso and head, 
with spine straight, well forward to edge of table. Then with hand 
upon ilium tilt it sHghtly forward, and with other hand upon shoulder 
rotate entire spine, including head, so that spine is locked and the point 
of locaHzation exactly corresponds to the lesions. This brings the spine 
back to nearly a straight position. Next, after a moment or two of 
tension-relaxation, either thrust back upon the shoulder or forward upon 
the iUum. Again exactly coordinating locahzation, relaxation and lev- 
erages is the key of the method. 

The Abdomen. — Direct treatment of the abdomen is given in 
many diseases of its organs. The patient should lie flat upon the back, 
the legs flexed upon the thighs and the thighs flexed upon the abdomen, 
so that the abdominal muscles will be thoroughly relaxed; and then 
the various organs of the abdomen can usually be manipulated with 
ease. Remember that in many diseases of the abdominal viscera the 
treatment of the splanchnics and vagi will be the primary treatment 
rather than direct abdominal treatments. 

In treating the liver directly, the ribs over the hver should be raised 
and separated, and the lower border of the hver manipulated directly, as 
considerable therapeutic results can be obtained, particularly when the 
liver is congested and enlarged. Manipulation of the bile ducts is 
very essential in many hver diseases. The treatment reheves congestion 
of the ducts and removes any collections of mucus in the ducts due to 
the congestion, as well as freeing obstructed flow of bile. The manip- 
ulation should be a deep, downward one, directly over the path of the 
ducts (from about the cartilage of the ninth rib to the duodenal orifice 
of the bihary tract, the latter being about one and one-half inches diag- 
onally downward and to the right of the umbihcus). Be very careful 
when first manipulating, and bear down lightly over the duct so that the 
structures superficial to it may be relaxed as the duct is deep below the 
surface of the abdomen. Usually the gall-gladder can be emptied by 
light pressure over the skin above the cartilages of the eighth, ninth and 
tenth ribs. The light manipulation acts, probably, by way of the spinal 
segment, as a stimulus to the dilators of the sphincters of the gall-bladder. 
Very likely through reciprocal innervation relaxing the sphincter of the 
bile duct will contract fibres of the gall bladder. 



78 The Practice of Osteopathy 

Manipulation of the stomach has considerable effect in strength- 
ening its circular fibres and toaing up the coats in general. In cases of 
gas formation, the gas in some instances may by manipulating over the 
stomach, be forced through the cardiac or pyloric orifices. 

Direct treatment over the spleen by raising the eighth, ninth, tenth 
and eleventh ribs of the left side is effectual in congestion and enlarge- 
ment of the organ. 

In thin subjects the kidneys can be treated directly by pressing 
down carefully but deeply over the kidneys, and lightly crowding them 
upward and outward. This treatment also has some effect in reliev- 
ing contracted tissues about the renal vessels and Iddneys. 

Treatment to the intestines through the abdomen is an effective 
treatment. In the various obstructions to the intestines, constipation, 
etc., the direct work is essential. Treatment of the intestines is to cor- 
rect any abnormal position that they may have assumed, to relieve con- 
strictions of the gut caused by contracted tissues, to relieve impactions 
and adhesions, to increase peristalsis and to tone up the intestinal coats 
in general. The treatment consists in a manipulation of the intestines, 
especially in the right and left iliac fossse, and the pelvic colon, ascending 
colon and duodenum, as impactions and prolapses of the gut are more 
liable to occur at these points than in any other locality. In manipu- 
lating the intestines, work for a definite purpose and not give a general 
kneading treatment unless the walls of the abdomen and the coats of 
the intestines are weakened ; in the latter case the spinal treatment is the 
primary one. In treating over the iliac region, draw upward and in- 
ward on the folds of the gut. It is claimed by some authorities that 
nerves pass from the cutaneous surface of the abdomen directly to the 
intestine by way of the peritoneum; if such is the case, manipulation of 
the abdominal walls would have direct effect upon these nerve fibres. 
The abdomen may be treated when the patient is sitting up, but the treat- 
ment is not satisfactory. (See Prolapsed Organs) . 

The Pelvis. — The treatment of the pelvis is easy, but the difficult 
work is in making a diagnosis of the position of the pelvic bones. The 
pelvis is especially apt to become deranged by jars and falls. Seme of 
the most successful osteopathic results have been obtained in correcting 
the pelvic region. 

To relax the muscles over the pelvis, the patient should be on the 
side or upon the face ; then relax the muscles by manipulating them up- 
w"a»i'd, chiefly those over the sacral foramina. It is a good rule to adjust 
the lumbar first owing to release secured to the nerves supplying pelvic 



The Practice of Osteopathy 79 

muscles and also to the fact that many pelvic distortions are secondary 
or compensatory to lumbar lesions. The easiest method to correct the 
innominata is to have the patient lie upon his side; then by standing in 
front of the patient slip one hand bteween the thighs and grasp around 
the tuberosity of the ischium, aad with the other hand upon the crest 
of the ihum, the innominatum can be moved upward or downward and 
forward or backward (wheel and axle principle). Simply pulling or 
pushing upon these two points in whatever direction necessary is all that 
is required providing the soft tissues are thoroughly relaxed. By hav- 
ing the patient flat upon the back practically the same treatment can 
be given, but not to so great an advantage. In cases where the ilium 
is posterior and the ischium anterior, the physician may stand back of 
the patient, while he is lying upon his side, and place one knee against 
the sacrum and with one hand upon the ilium, with the other take hold of 
the ankle of the affected side (the involved side being uppermost in all 
cases where the patient is Ijdng upon his side) ; pressure can be exerted 
upon the ilium and the limb pulled backward, thus correcting the de- 
rangement. This treatment should be avoided as much as possible, as 
there is considerable danger of pulling back too severely and injuring 
the patient; the lever is long and the amount of force exerted upon it 
cannot be judged precisely. 

Another method is, with the patient on the back, flex and evert the 
knee to the side so the side of the foot lies flat on the table. Grasp the 
ankle with one hand and with the other on the crest of the ihum of the 
opposite side then, by pushing down firmly on the knee the articulation 
is gaped and at the same time the operator pushes with his body against 
the knee with a sharp thrust. This may have to be repeated a few times 
before the articulation is released and if one is keen he will easily de- 
tect the slight concussion carried down the femur as the adjustment 
takes place. This will correct a forward and downward innominate. 
For an upward and backward one, place the patient in exactly the same 
position and go through the same motions except that the knee is pulled 
toward the operator. If the desired "chug" is not felt and adjustment 
is not definite, the leg may be pulled down rather smartly by the ankle 
to a parallel with the other. This is a technique that is easy, both for 
the patient and operator, and will correct any but the most stubborn. 

In the case of a greatly relaxed and atonic condition of the ligaments 
of the. pelvis much trouble is experienced, often, in making the adjust- 
ment permanent. Many suggestions have been made and most of them 
useless but, probably the use of a belt of non-elastic webbing about two 



80 The Peactice of Osteopathy 

inches in width buckled tightly around the pelvis just below the anter- 
ior spines will do as much as anything and is a procedure well to follow 
in all such cases. Where there is a pendulous abdomen a support in 
the shape of a simple belt which should be so fitted as to act as a sling 
will transfer the weight of the abdominal viscera from the muscles, al- 
read}' stretched and atonic, to the belt and put the burden over the sa- 
crum. This prevents the pulling of the innominatum in lesion again. 
Overcorrection is suggested as a means on the ground that it sets up 
irritation and induces fibrous ankylosis and for the same reason W. W. 
Howard places his patient prone and with thumb works the ligaments 
associated with the joint until they are thoroughly inflamed. The pa- 
tient is then put in bed a few days and after the inflammation has cleared 
up the ligaments will be found to have shortened. 

To correct a rotary lesion between the pelvis and fifth lumbar the 
patient should be placed upon the side, and with the body held firmly, 
the pelvis can be forced backward or forward as the occasion demands. 
(See Coccyx). 

The Legs. — The origin of many symptoms manifested in the legs, 
as in the arms, are due to spinal lesions corresponding to the region of 
innervation to the affected tissues. The derangements of the pelvic 
bones are a frequent source of symptoms that are referred to the legs 
and feet. The osteopath finds that a shght dislocation of the hip may 
occur which is especially likely to affect the knee. This partial disloca- 
tion is apt to be an upward-posterior one; the head of the femur resting 
in the upper and posterior part of the acetabulum. Many diseases of 
the legs and feet are due to local displacement of the bones. The meth- 
od of treatment is the same as given in surgical works. (See Sprains). 

A general treatment of the legs and thighs is oftentimes necessary; 
it consists of flexing the thighs quite firmly upon the abdomen, and exe- 
cuting thorough external and internal rotary movements of the thighs 
and legs. In a few cases both limbs are flexed strongly at the same time 
upon the abdomen. After giving these movements manipulation over 
the saphenous opening and beneath the popliteal space is performed. 
This genaral treatment teads to increase the circulation of the entire limb 
and to relax thoroughly all contracted fibres. 

The Arms. — In treating the arms, care has to be taken that the 
affection is not due to spinal derangements; otherwise the arms are manip- 
ulated according to the disorder. Complete dislocations of the shoul- 
der comes under the province of surgery. Many times the osteopath 
locates slight or incomplete dislocations of the shoulder. Partial dis- 
locations of the shoulder are generally anterior. (See Sprains). 



The Practice of Osteopathy 81 

In cases where pain exists in the shoulder or arm, outside of locat- 
ing the cause in the shoulder joint, the affection may be due to fibres 
contracting over the coracoid process, or a dislocation of the second or 
third rib, and in some instances the clavicle is deranged. Special care 
should be given to a possible bursitis and tendo-synovitis. Occasion- 
ally muscular fibres may shp out of the bicipital groove. Dislocations 
of the bones of the arm are treated according to surgical methods. The 
pains and various troublesome symptoms that may be manifested in 
the fingers or the hands are oftentimes caused by slight dislocations of 
the elbow, shoulder, ribs, or vertebrae, as low as the sixth to eighth dor- 
sals. 

The coccyx. — The coccyx, owing to its exposed position and rather 
unstable attachment, is subject to many injuries; more indeed than 
come to notice. Its injury results in many local and general disturbances 
owing to its close relation to the sympathetics. Successful treatment of 
deviations often bring startling results. They may be divided into 
fractures and displacements. 

In complete or partial fracture of the coccyx, as well as in dis- 
location, if the patient can be seen with reasonable promptness after 
the accident much can be done for relief of the pain and the prognosis 
is good for complete recovery. 

Examination should be made externally and internally and after 
the condition is diagnosed about the same procedure is indicated for 
any of the conditions. With the patient on the left side introduce the 
right index finger, well lubricated, into the rectum and carefully relax 
all tissue within reach of the tip. If there are spasms of the coccygeal 
muscles, inhibition of the anterior nerves will quiet them. When this 
has been done place the left index finger externally along the body of 
the coccj^x and holding it firmly both within and without release it lon- 
gitudinally and then adjust. After this has been done it is well to hold 
it there until all danger of returning spasm, which might displace it 
again, is over, when the finger can be withdrawn. 

The pain following will depend on the severity of the injury, but 
will keep up more or less constantly for several days. When severe, re- 
lief is often given by introducing the finger and relaxing contracted tissue 
which is pulhng it from its position. Hot water bags placed next to the 
part will be of benefit. The bowels should be kept confined for forty- 
eight hours if possible in cases of fracture. Watch carefully the progi-ess 
of union that the bones are in situ so there will not be deformity. 

In diagnosing the first injury be sure that there is no splitting of the 



82 The Practice of Osteopathy 

first segment or splinters which may require surgical interference. In 
old cases of fracture where there is complete bony ankylosis it is not justi- 
fiable to attempt any change, but where there is motion and a fibrous 
union, after preparatory treatments about one week apart, it can usually 
be replaced. Look well to any muscular contractions which might in- 
terfere with it. Force must never be used nor any attempt to replace 
until it has been first released from its articular attachment. In the 
various forms of displacement the same technique applies as in frac- 
tures, or the finger and thumb of one hand may be used, the tip of the 
finger internally at the sacro-coccygeal articulation and the thumb ex- 
ternally at the same point. Complete control of the part is secured in 
this manner. Great care must always be used in treatment of any dis- 
placement of the coccyx. Contractions of. its muscular attachments will 
often cause deviations in contour. Removal of the irritation and re- 
laxation will allow it to assume its normal position. 

The sacrum. — Adjustments of the sacrum as distinguished from 
the ilium in strictly innominate lesions are not many. When posterior 
with tha patient on a stool the knee of the osteopath coveted by a pillow 
and placed against the sacrum and both hands grasping the anterior 
borders of the ilia, strong traction will move it into position. In a down- 
ward displacement with the aid of an assistant from behind holding the 
crests of the ilia firmly as the patient sits on the table, the osteopath in 
front clasping both arms about the patient and with a rocking motion 
from side disengages the sacrum and at the same time lifts it into posi- 
tion. 

For anterior displacements use the technique described in replacing 
upward and backward innominate dislocation first right side and then 
left, which will result in correcting the lesion. 

The preceding osteopathic technique includes a few of the treat- 
ments given by the osteopath. Although many osteopaths use methods 
not given here, those outlined are sufficient for illustrative purposes. 
A point which cannot be too thoroughly impressed upon the student is 
that osteopathic treatment is in reality constructive work, that is, re- 
adjustive, not only in detail, but in viewing the body structure as a whole. 
Detailed readjustment is an essential, still do not lose sight of the re- 
lation of the part to the whole. In our distinctive work anatomical con- 
struction is the basis of physiological function, although physiological 
stimulus is essential to anatomical development. 

How often to treat. — How often to treat a case depends entirely 
upon the nature of the disease from which the patient is suffering. Just 



The Practice of Osteopathy 83 

as in giving drugs the frequency of treatment is entirely dependent upon 
the seat of the disease and its severity. Acute cases require a thorough'^ 
treatment at least once daily, and many times in severe cases the treat- 
ment has to be repeated several times daily. In subacute and chronic 
cases, as a rule, treatment should not be given as often as in acute cases; 
possibly once a day, but usually alternate days is better. In office prac- 
tice cases are commonly treated two or three times weekly. Still it is 
better not to treat some cases oftener than once a week. 

There is more danger in treating too often and too long than in not 
treating often enough. The distinctive work of an osteopath is to cor- 
rect disordered anatomical structures; and when a certain derangement 
has been corrected the tissues should have rest and plenty of time for 
repair. When treatments are given often, it simply keeps the tissues in 
an irritated state and nature does not have time to heal the diseased tis- 
sues. Always make it a point at each treatment to correct some definite 
lesion, and when the work is accomplished let the parts alone until the 
tissues have recovered as much as possible from the effects of the previous 
treatment before another treatment is attempted. The reason why 
some cases do not get cured under osteopathic treatment is simply be- 
cause the osteopath keeps the diseased tissues in an aggravated state by 
the constant treatment so that they do not have the least chance to 
heal; the physician is thus adding irritation to the disease. 

It is only by experience that one can tell how often to treat. Each 
case is a special study; what would be quite sufficient for a certain indi- 
vidual with a given disease would not be at all suitable for a second indi- 
vidual with the same disease. As in drugs what is suitable for one person 
would not be adapted to another, because the make-up of each individ- 
ual is entirely different; but here the parallelism diverges, for in drugs 
there is a foreign agent introduced into the system, while in osteopathic 
treatment the curative agent is entirely harmonious with the idiosyncra- 
sies of the individual. It is for this reason that experience in practice 
is so essential. 

Most cases should not be treated, as a rule, after a meal unless the 
patient is suffering from some digestive disturbance ; for treating other 
regions of the body outside of the digestive tract causes more or less 
stimulation of the parts treated and thereby draws blood away from the 
organs of digestion. Cases of disordered brain circulation, where the 
patient is unable to rest or sleep at night, should be treated at about 
their retiring time so that the circulation of the body may be equalized, 
thus giving the patient undisturbed rest. 



84 The Practice of Osteopathy 

To show in a practical way the methods of experienced osteopaths 
^in this matter G. J. Helmer^ is quoted: "I submit the following table 
to illustrate the frequency of treatment in one hundred cases taken from 
my practice : one case three times per week, sixty-three cases two times 
per week, twenty-two cases one time per week, nine cases once every 
two weeks, five cases once every four weeks. Comparing the present 
with the past, I find I am lengthening the time between treatments with 
much better results. " 

Another very practical side of the question and one which will be 
greatly appreciated by the patient, is the lessened cost for the same re- 
sult in the less frequent treatments, as well as the saving in time. With 
the loss in going to the office, rest after treatment, not to mention pos- 
sible wait while there, three times weekly represents more time than 
the average person can well spare and not infrequently will deter him from 
continuing. More especially is this true of those coming from a dis- 
tance. 

Length ol Treatment and Overtreatment. — Naturally the 
length of treatment depends upon the case at issue and nothing more. 
There is no reason why any two cases should be treated for the same 
length of time unless they present identical lesions and then the personal 
equation of the two might present such a wide difference of aspect as to 
forbid such a proceeding. 

The question of time has no place in the matter, save that it must 
not exceed physiological hmits and be sufficient for the needs of the case. 
The patient should understand at once that it is to accompHsh a spe- 
cific purpose that the treatment is given, just as definite as a surgical 
or dental operation, and when the work is done it is time to stop. He 
would hardly be attracted to the dentist who guaranteed to use forty- 
five minutes in extracting a tooth. Good judgment is required in this 
as in all matters pertaining to osteopathy. There is a generally ex- 
pressed opinion among the older osteopaths, based on experience, that: 
first, a short specific treatment is productive of best results and, second, 
treatments given under high tension when quick work is necessary are 
most satisfactory. Long treatments are debiUtating and over stimula- 
tion amounts to inhibition. Further, in a long treatment it is necessary 
to go over the whole body, thus dispersing the vital forces (which have 
been stimulated for heahng and upbuilding the pathological area) to 
parts not involved, thus defeating the very purposes intended. Dr. 
Still always advocated and gave the short, specific treatment. 
1. Journal of the American Osteopathic Association, Dec, 1903. 



The Practice of Osteopathy 85 

The point always to be considered is the individual characteristics 
of the patient, and effects of the first treatment should be carefully ob- 
served. After a patient has been under treatment for any considerable 
time it is well to give him a vacation from treatment, and it is remarkable 
what improvement will be shown at times by such a measure and how 
seldom he will lose ground. Dr. Still presented this subject vividly 
as follows: "To treat the spine more than once or twice a week 
and thereby irritate the spinal cord, will cause the vital assimila- 
tion to be perverted and become death producing by effecting an ab- 
sorption of the living molecules of life before they are fully matured 
and while they are in the cellular system, lying immediately under the 
lymphatics. If you will allow yourself to think for a moment of the 
possible irritation of the spinal cord and what effect it will have on the 
uterus, for example, you will reahze that I have told you a truth. Many 
of your patients are well six months before they are discharged. They 
continue treatment because they are weak, and they are weak because 
you keep them so by irritating the spinal cord. " It is not a rare exper- 
ience for a patient to leave apparently with httle or no improvement 
only to report a complete recovery a httle later. 

Misapplied Treatment. — Probably in spinal treatment more risks 
are taken than in any other region of the body. To us as a school it is 
by far the most important and interesting area we have to treat, conse- 
quently it is not surprising that various general treatments and meth- 
ods have been devised with the idea of getting quicker and easier results. 
Herein hes the danger outside of mistaken diagnosis, for short cut treat- 
ments can never take the place of time and skill. Technically speaking, 
if one thoroughly understands the philosophy of osteopathy and is con- 
versant with the underlying principles of its therapeutics, there is ab- 
solutely no danger of even the slightest injury. It is the one who takes 
chances by not properly diagnosing and by not being cautious enough 
with delicate persons when applying his treatments that is apt to over- 
strain some tissue or organ and otherwise do bodily harm. Of the treat- 
ments considered dangerous not one of them is without merit if judi- 
ciously applied, but unfortunately in many cases they are in general 
and indiscriminate use. It is well to remember that we are moving 
structures which have never been moved before and that time enough 
has not elapsed to observe what the ultimate result may be. Again, in 
adjusting a subluxation of the spine do not forget that the force necessary 
for that adjustment, if misappUed, is sufficient to produce a lesion, and 
there is no doubt that this has happened. Your patient's interests are 



86 The Practice of Osteopathy 

above everything and must never be sacrificed for any reason what- 
ever, so if at any time there is uncertainty always give the patient the 
benefit of the doubt. On the other hand the osteopath must have the 
courage of his convictions and fortunately when these are coupled with 
good judgment the results are all that could be desired. The following 
should be used with great caution if used at all: 

First, Indiscriminate stretching of the spinal column with the 
aid of an assistant. It is not good osteopathy although there are some 
cases where it may be beneficial. While not specially dangerous, gen- 
erally, in deUcate patients, elderly people, arterio-sclerotic conditions, 
and in some stages of Pott's disease it is absolutely contra-indicated. 
Moreover in most spinal cases except impacted vertebrae and symmet- 
rical curvatures the stretching of the vertebral Hgaments locks the lesion 
firmer. 

Second, Extreme rotating of the cervical region. This cannot 
be considered good treatment in any case with the exception of the muscle 
stretching. On the contrary it is dangerous; first, it is not osteopathy 
for it is not specific; second, the nervous shock is severe, an important 
consideration in dehcate people; third, the cervical Hgaments become 
stretched and the vertebrae are easily displaced, while damage to a dis- 
eased vertebra, an aneurism or in arterio-sclerosis would be irreparable. 
No other region of the body should have greater care in treatment than 
the neck. 

Third, Hyper-extension of the spine with the patient on his face. 
This treatment is rarely indicated. In fact, it is barbarous and a rehc 
of an early day. Possibly more cases have been injured by this treat- 
ment than all others combined. 

Fourth, Rough separating of the vertebrae and ribs while the pa- 
tient is on his face. This is a most excellent treatment in many cases, 
but great judgment is necessary. Delicate patients, heart disease, and 
necrosed vertebrae and ribs should be carefully excluded. 

Fifth, Innominate adjustments such as placing the patient on 
the side and putting the knee against the sacrum while grasping the leg 
at the knee. Or, the placing of the patient face down with one hand on 
the sacrum and the other holding the knee. In both these there is a 
tremendous leverage and in the latter the strain is at the lumbar rather 
than where needed. There are other unnecessarily risky methods for 
this operation, while it is easy to perform in most cases and without 
danger. 



The Practice of Osteopathy 87 

Sixth, Abdominal treatment gives wonderful results when in- 
telligently applied, but it may be productive of great harm in conditions 
of tumors, malignancy, and pus formations. 

Misapplied treatment is alwaj^s dangerous, no matter to what 
part of the body given, and it is proof of wrong diagnosis when given. As 
a rule treatment is given without proper diagnosis in such cases, so a mis- 
appKed treatment has two interpretations — first, ignorance; second, 
laziness. In the former lies the greater danger for ignorance coupled 
with force and lack of skill is an appalHng combination. 

Cases are frequently reported where tumors have passed from the 
vagina, rectum, nose, etc., the osteopath thinking it was the result of 
good treatment, without considering that it was simply the breaking of 
a long pedicle with great danger from hemorrhage. The greatest care 
should be exercised in treating cases where aneurism, osteomalacia, and 
arterio-sclerosis are present, also in the leg treatment of tabes dorsahs 
and in the weak, thin ribs of elderly people and those with a gouty or 
rheumatic diathesis. Imagine treating an abscess directly, yet it has 
been done, as have varicose veins with the terrible danger of rupture 
and embolism. Aneurisms have been ruptured in the same way. 

One could go on indefinitely with this subject, but to sum up: if 
the osteopath is not familiar with the feel of the living anatomy in its 
giving and resisting under treatment both in health and disease and does 
not know his osteopathy, nothing can prevent him doing harm. A suc- 
cessful practitioner means an understanding of pathology, then exper- 
ience plus common sense. 



The Practice of Osteopathy 



OSTEOPATHIC CENTERS 

"Osteopathic spinal centers" was a term commonly used in the early 
period of osteopathic development. From the facts, first, that a few 
centers have been actually determined in the cord, viz., genito-urinary, 
vaso-motor, etc.; second, that the innervation from the spinal segment 
to various thoracic, abdominal and pelvic viscera correspond with a 
considerable degree of accuracy to certain vertebral sections, and third, 
displacements of tissues of the spinal column affect viscus integrity, de- 
pending upon the locality of the structural perversion as to the organ 
involved and is a clinical observation of great import, arose the mis- 
nomer "osteopathic centers." For one to ask what "centers" should 
be "treated" in this or that disease shows a lack of the conception of os- 
teopathy as if he asked what "movements" to give when "treating" a 
certain disorder. It is as unosteopathic, as it is unscientific, broadly 
speaking, to suppose osteopathic technique implies the application of 
movements to certain nerve centers. 

Osteopathic Stimulation 

"Osteopathic stimulation" is another term loosely used without ex- 
tensive clinical experience to support it. Mechanical stimulation is fre- 
quently utilized in the physiological laboratory. But to employ it ex- 
tensively and comprehensively in the treating room or at the bedside the 
therapeutic potency of it will be found wanting; that is, to employ it to 
the exclusion of that most important basic treatment, readjustment, is a 
great mistake. 

Chnically, the pathologically slowed heart may be stimulated by a 
stimulus to the cervical sympathies, the gall-bladder emptied by a stim- 
ulus near the costal cartilages of the ninth and tenth ribs (this is probably 
via the spinal segments), etc. Normally, these organs and others may be 
temporarily stimulated. Experimentally, Burns^ of Los Angeles and 
Pearce" of San Francisco have shown the potency of osteopathic me- 
chanical stimulation. For example, stimulation (mechanical) in the 
middle and lower dorsal regions irritates and increases peristaltic action 
and vaso-constriction in the stomach and intestines. 

1. Burns — Partial Report of Experiments upon Visceral Reflexes. The Os- 
teopathic World, Aug., 1905. 

2. Pearce — Some Laboratory Demonstrations of Osteopatliic Principles. The 
Osteopathic Physician, Nov., 1905. 



The Practice of Osteopathy 89 



Osteopathic Inhibition 



Likewise the term "osteopathic inhibition" has not always been 
scientifically employed. Mechanical inhibition is probably used less 
frequently than stimulation but still it is of more importance. Prob- 
ably the true interpretation of considerable of so-termed stimulatory 
and inhibitory efforts, is simply one of normahzation of tissues, physio 
logic equihbrium resulting from such changes. 

CHnically, to relax contracted muscles by inhibition, to relieve neu- 
ralgia by impinging nerve courses, to relax the cardiac orifice of the 
stomach by pressure at the ninth or tenth dorsal vertebra on the left 
side, etc., are excellent examples of the therapeutic value of inhibition. 
Experimentally Pearce and Burns produced the opposite results to that 
of stimulation. Inhibition in the middle and lower dorsal region caused 
relaxation of the muscles of both the stomach and intestines, decreased 
peristalsis, and caused dilatation of the blood vessels. 

The employment of stimulation and inhibition rounds out to a 
certain extent our therapeutics, that is, makes it more practical and spe- 
cific. We should not, however, over-rate the relative value of stimulatory 
and inhibitory treatment as compared with the readjustive treatment. 
Not but what the former is of considerable practical importance, but 
the point to be emphasized is that it gives a scientific demonstration of 
how pathological effects result, if long continued, from the various os- 
teopathic lesions: In a word, it shows the physiological process from 
cause to effect, or rather a step in the beginning pathological (perverted 
physiological) in many disturbances. 

Therapeutically, all will agree with Cherry^ that "stimulation and 
inhibition should be employed in all forms of acute disease as palliative 
measm-es until such time as the primary lesion may be removed." 

As a preparation for adjustment of any bony lesion there is no 
question but that simple inhibition for a brief time in the area will bring 
about relaxation of soft tissues in a much more satisfactory manner 
than the usual massage like method. McPherson, Montreal, has de- 
veloped a technique of sacral pressure which he uses exclusively in his 
practice. Without going into the merits of his theory there is no doubt 
that inhibition at the second and third sacral will bring about relaxa- 
tion of the muscles of the lower trunk in a most gratifying manner. An- 
other thing, if there is difficult}^ in introducing the finger in making either 

1. Stimulation — Leslie E. Cherry, Journal of the American Osteopathic Asso- 
ciation, Feb., 1905. 



90 The Practice of Osteopathy 

a vaginal or rectal examination, a minute's pressure at these points 
will, in most eases, cause the sphincter to relax so as to cause no discom- 
fort to the patient. This pressure will, also, have a great effect on the 
hypogastric plexus and the pelvic organs. 

Osteopathic Readjustment 

Readjustment or adjustment is many times particularly emphasized 
in this work as the key to osteopathic therapeutics. 

If the theory of readjustment can not stand the most searching 
tests of science osteopathy will have to be relegated to a most subservient 
place, on a par with massage, Swedish movements, and various medical 
gj^mnastics. Consequently the readjustment theory is again referred to, 
and especially so when the subjects of osteopathic centers, stimulation 
and inhibition are outlined. 

No doubt many stimulatory (so-called) and general treatments ex- 
ert their greatest influence by inadvertently readjusting tissues. Then 
how much more effective would the readjustment treatment be if applied 
intelligently. In certain acute disorders, e. g., "colds," immediate 
relief is often obtained by relaxing muscles through either stimulation 
or inhibition; in reahty the final result, as far as the muscle is concerned, 
is one of readjustment. Likewise in stretching and rotation of tissues 
and sections of the body the effect may either be stimulatory or inhibitory, 
and still it may be, also, readjustive. 

After all has been said the ultimate physiological effect of anj^ of 
these treatments, if of any therapeutic value, must be one of stimula- 
tion to a part or to the body generally. But there is a vast difference 
between physiological stimulation and the one method of obtaining the 
same termed mechanical stimulation. It is not the purpose here to enter 
into anything Hke an exhaustive survey of stimulation and inhibition 
but simply to outhne a few practical hints on the relative values. Every- 
one is aware that over-stimulation is equal to inhibition, and even apply- 
ing it to very deUcate subjects the therapeutic end we may wish to obtain 
may be lost and as a consequence the patient exhausted; whereas 
at the same time readjustment possibly could have been employed and 
real permanent effects secured. 

So we should whenever possible utihze the basic principle of our 
therapeutics, readjustment, for tliis represents in the majority of cases, 
first, permanent results; second, a saving of much time, and third, less 
exhaustion on the part of both patient and physician. 



The Practice of Osteopathy 91 

McConnell^ has shown in his series of laboratory experiments on 
animals the reaUty and potency of the readjustment fundamental. The 
effect of malaHgned vertebrae and ribs upon contiguous vascular chan- 
nels and nervous tissues, not only affects immediate skeletal muscles by 
simple contractions but even produces interstitial myositis. Through 
narrowing of the intervertebral foramina and tension upon the fibrous 
tissue anchoring the spinal nerve in its exit, and through pressure and 
strain on the sympathetics in contact with the heads of the ribs, which are 
secured there by the parietal layer of the pleura, organs in corresponding 
cavities become diseased. Some of the diseases produced in the series 
of experiments were catarrhal and parenchymatous changes in the stom- 
ach and intestines, congestion of the liver and spleen, acute nephritis, 
goitre, inflammation of the lymphatics, edema of the cornea, and degen- 
erations of nervous tissues. Still too much emphasis should not be 
placed upon the narrowing of the foramen for certain pathologic changes 
are shown to be due to other conditions than Wallerian. 

The osteopath, as stated, may inadvertently correct osteopathic 
lesions. Vis medicatrix m(!.z^i^r«<?undoubtedly corrects many osteopathic 
lesions; this is evident from the fact that many bodily strains, sprains, 
and injuries are overcome naturally or involuntarily, that is, without 
any voluntary assistance from an osteopath. On the other hand all 
osteopathic lesions are not due to outside influences or forces, e. g., in 
pneumonia the severely contracted dorsal muscles often partially dis- 
locate the vertebral ends of the ribs and thus increase the seriousness of 
the disease; and this is true in many acute conditions wherein visceral 
changes will reflexly contract spinal muscles and also through these 
contractions produce osseous lesions. Here is where osteopathic 
treatment in acute diseases will not only correct the primary lesion but 
also these secondary ones and thus abort, or shorten, or lessen severity, 
or prevent complications of the disease. But it should always be borne 
in mind that when certain disease processes occur it will take a definite 
time at best for curative changes to predominate. In other words patho- 
gological changes are just as real and potent as physiological facts or 
anatomical data and the character of the same should always be con- 
sidered. 

Consequently in readjustment work a distinctive etiology and path- 
ology has to be taken into account. The color, contour (whether the 
lesion is simply a local one or there is a composite or group lesion), con- 
1. McConnell — The Osteopathic Lesion, — Journal of the American Osteopathic 
Association. 



92 The Practice of Osteopathy 

dition (irritation, debility, contractions, and tenderness), and movement 
of the several regions, and the spine as a whole should be noted. And 
the student should always keep in mind that the osseous vertebral lesion 
may be, (a) a twist between two vertebrae (this generally means a ro- 
tation of one section of the spine on another section), (b) malalignment 
of several vertebrae (the composite or group lesion), or (c) the impacted 
or strained lesion, (this is a lesion that Clark attaches considerable sig- 
nificance to, wherein there is injury to the articular surfaces and Hga- 
ments without osseous derangement, followed by exudation and other 
inflammatory products, limited motion, etc.). 

Vaso- Motor Nerves 

It is extremely important that the osteopath should be thoroughly 
conversant with the regions where he may affect the vaso-motor nerves 
to A^arious tissues and organs. Many anatomical derangements un- 
doubtedly involve the vaso-motor nerves, and it is therefore necessary 
to know where they may be affected. The following table is taken mostly 
from the physiology of Landois and Stirling, but many of the statements 
have been noted at various times; it is, therefore, impossible to give full 
credit.^ 

The vaso-motor center is in the medulla, consequently the osteo- 
path gives cervical treatment to influence this center. ' Treatment of the 
upper cervical region has undoubtedly a marked effect in tending to 
equalize the vascular system of the body, when it is disturbed. 

Head. — The cervical sympathetic for the same side of the face, 
eye, ear, salivary glands, tongue, etc., and possibly the brain. Lesions 
are found in all the tissues about the cervical region, but usually in the 
vertebrae, which influence these nerves. Deep contracted muscles 
oftentimes involve them. The spinal vaso-constrictors for the vessels 
of the head are from the first five or six thoracics. Many lesions are 
located in the upper five or six dorsal vertebrae, or corresponding ribs, 
that have apparently a direct influence upon the vessels of the head. 
Not only congestive headache and congestion of the brain tissues are 
influenced by lesions in this region, b\it disease of the eye, ear and face 
occasionally arise from such derangements. It is always best when the 
head, neck or even the arms are involved, to examine carefully this re- 
gion. Vaso-dilator fibres for the face and mouth are found from the 
second to the fifth dorsals; these fibres unite almost entirely with the 
trigeminus, and pass from the superior cervical ganghon of the sympa- 

1. See also Gaskell, The Involuntary Nervous System; Pattenger, Symptoms of 
Visceral Disease; Mackenzie, Symptoms and Their Interpretation. 



The Practice of Osteopathy 93 

thetic, to the ganglion of Gasser. This fact is of great importance to 
the osteopath, for oftentimes when inflammation of the face and mouth 
occurs, lesions may be located along the upper dorsal vertebrae or ribs, 
or in the deeply contracted muscles of this region. Observation revealed 
in several cases of erysipelas that the causative lesion was located in the 
upper dorsal region; and the cases were cured by correcting these lesions, 
'thus showing that probably the vasomotor nerves were the seat of the 
trouble. Other dilator fibres arise apparently in the trigeminus, for 
stimulation of this nerve between the brain and Gasser's gangHon causes 
dilatation of the vessels of the face. The lingual and glosso-pharyngeal 
nerves are the dilators of the lingual vessels. The sympathetic and 
hypo glossal are the constrictors; these arise in the s^mipathetic and 
reach the nerves by way of the superior cervical ganghon. Stimulation 
of the cervical sympathetic causes constriction of the retinal vessels. 
This point is extremely interesting to the osteopath, because diseases of 
the retina and optic nerve are oftentimes due to subluxated cervical 
vertebrae, usually the atlas or third cervical. The retinal fibres leave 
the sympathetic at the superior cervical ganghon and pass along the 
communicating ramus to the gangHon of Gasser, from whence they reach 
the eye through the ophthahnic branch of the fifth nerve, the gray root 
of the ophthalmic, the ganglion and the cihary nerves. Almost all the 
fibres to the anterior part of the eye are found in the fifth nerve; this, 
also, is another important point for the osteopath's consideration. Cases 
of conjunctivitis, keratitis, corneal astigmatism and diseases about the 
eyehds and tear ducts are usually caused by lesions to the fifth nerve, 
due to a deranged atlas or third cervical. The vaso-dilators for the an- 
terior part of the eye, and also dilating fibres to the iris may be affected 
at the first and second dorsals. This point is also taken advantage of 
by the osteopath, for lesions of these fibres occur oftentimes at the upper 
dorsal. It is claimed that important fibres that aid in the control of 
the mctabohsm of the retina, may be affected at the fourth and fifth dor- 
sals. 

Lungs. — Reflex constriction by stimulation of the intercostals, 
central end of the sciatic, abdominal pneumogastric and abdominal sym- 
pathetic. There is not a rich vasomotor supply.^ The essential feature 
to the osteopath is that the vaso-cunstrictors to the lungs and bronchial 
tubes are very hkely to be interfered with by rib and vertebral disloca- 
tions, from the second to the seventh dorsals, inclusive, but chiefly at 
the third, fourth and fifth. The heaviest innervation being from the 

1. MacLeod, Physiology and Biochemistry in Modern Medicine. 



94 The Practice of Osteopathy 

third, fourth and fifth spaces, probably explains why asthma is often 
due to a dislocation of the third, fourth or fifth rib. 

Heart. — First to fifth thoracic via ganghon stellatum and inferior 
cervical ganglion. Vaso-motor fibres to the coronary arteries are found 
in the vagi. 

Intestines. — Sympathetic, chiefly through the splanchnic nerves. 
Vaso-constrictors of the jejunum from the fifth dorsal down, for the ileum 
shghtly lower and for the colon still lower. There are none below the 
second lumbar. Dilators are present in the same sheath, but more 
abundant in the last three dorsals and the upper two lumbars; all prob- 
ably end in the solar and renal plexuses. 

Receptaculum Chyli. — Stimulation of the splanchnics causes 
dilatation. 

Liver. — The splanchnics chiefly on the right side. The vagus 
contains vaso-dilators. There are also fibres from the inferior cervical 
ganglia of the sympathetic. 

Kidneys. — Vaso-motor nerves from the sixth dorsal to the second 
lumbar, but principally from the ninth to twelfth dorsals, inclusive. 
In the large majority of kidney diseases, lesions are found from the tenth 
to the twelfth dorsals. Stimulation of the sciatic centers causes con- 
traction. There are also fibres from the superior cervical ganglion. 

Spleen. — Vaso-motor fibres are in the splanchnics, third dorsal to 
third luml^ar, principaUy, on the left side. There are some fibres direct 
from the brain. Stimulation of the vagi contracts the spleen. 

Portal System. — Fifth to ninth dorsal. 

Generative Organs. — For Fallopian tubes, uterus, vagina, vas 
deferens and seminal vesicles, vaso-motor fibres are found in the lower 
dorsal, and the second, third, fourth and fifth lumbar nerves, principally. 

Coccyx and Immediate Region. — Third lumbar down. 

Back Muscles. — Dorsal Posterior branches of the lumbar nerves 
and intercostal nerves. These nerves arise from, the gray ramus of the 
corresponding sympathetic ganglia. 

Arm. — From the brachial plexus, the sympathetic, inferior cervical 
ganglion and first thoracic ganglion, and sometimes lower. 

Leg. — Second dorsal down, the sciatic and crural nerves, and the 
abdominal sympathetics. 

Sensory Nerves 

Inhibition of various regions along the spinal column is frequently 
given by the osteopath to lessen pain. It is only a temporary or palli- 
ative treatment, but many times gives great relief. One should inhibit 



The Peactice of Osteopathy 95 

usually over tender points and contracted muscles. These (tender 
points and contracted muscles) are signs to the osteopath that disturb- 
ances exist at these points. The following table is taken from Quain, 
which is Head's classification: 

Heart. — First, second and third dorsals. 

Lungs. — First, second, third, fourth and fifth dorsals. 

Stomach. — Sixth, seventh, eighth and ninth dorsals. Cardiac end 
from sixth and seventh. Pyloric end from ninth. 

Intestines. — (a) Down to upper part of rectum, ninth, tenth, elev- 
enth and twelfth dorsals, (b) Rectum, second, third and fourth sacrals. 

Liver and Gall-bladder. — Sixth, seventh, eighth, ninth and tenth 
dorsals. 

Kidney and Ureter. — Tenth, eleventh and twelfth dorsals. Upper 
part of ureter, tenth dorsal. At lower end of ureter, first lumbar tends 
to appear. 

Bladder. — (a) Mucous membrane and neck of bladder; (first) 
second, third and fourth sacrals; (b) over distension and ineffectual con- 
traction, eleventh and twelfth dorsals, and first lumbar. 

Prostate. — Tenth, eleventh (twelfth) dorsals. First, second and 
third sacrals, and fifth lumbar. 

Epididymis. — Eleventh and twelfth dorsals and first lumbar. 

Testis. — Tenth dorsal. 

Ovary. — Tenth dorsal. 

Appendages, etc. — Eleventh and twelfth dorsals, first lumbar. 

Uterus. — (a) In contraction, tenth, eleventh and twelfth dorsals, 
and first lumbar, (b) Os uteri; (first) second, third and fourth sacrals 
(fifth lumbar very rarely). 

Other points are used by the osteopath to reheve pain of certain 
regions, for such the reader is referred to the article on neuralgia; be- 
sides many tender points are found along the spine by the osteopath, 
where inhibition gives rehef to the patient, provided such points have a 
connection with the case in question. 

Hot fomentations if properlj^ apphed, through reciprocal relation- 
ship of the nervous system, are of value in relieving pain, releasing spastic 
musculature and normalizing visceral function. Frequently, in both 
acute and chronic cases, this is an excellent preparatory measure, to be 
followed by careful adjustment. It will be recalled that the functional 
test, movement of a vertebral lesion is of primary consideration.^ 

1. See Luciani, Human Physiology, Vol. Ill; MacLeod, Physiology and Biochem- 
istry in Modern Medicine. 



96 The Practice of Osteopathy 

PATHOLOGICAL SPINAL CURVATURES 

Spinal Curvatures 

Any deviation of two or more consecutive vertebrse from the normal 
curves of the spinal column is usually termed by the osteopath a patho- 
logical curvature. Of the common pathological curvatures of the spinal 
column there are found: (1) scoHosis or lateral curvature, (2) kyphosis, 
or excurvation, an antero-posterior curve with the convexity backward, 
and, (3) lordosis, or incurvation, an antero-posterior curve with the 
convexity forward. 

Osteopathic Etiology. — Of primary importance in the causation 
of pathological curvatures of the spinal column, are injuries to the spine, 
such as strains, falls, blows, and various phj^sical forces, acting directly 
or indirectly, as injuries to the chest, pelvis and limbs. The osteo- 
path in his daily work finds more curvatures, as well as acute and chronic 
diseases, resulting from some simple injury to the spine, as a slip, strain 
or twist, than from any other cause. The dire effects of any violence to 
the spinal column cannot be overestimated. 

Among predisposing causes may be mentioned, continued ill 
health, general weakness, rapid growth, rachitis, tuberculosis, etc. Any 
habitual one-sided position may result in a curvature. An injury to the 
chest, adhesions from pleuritis, chronic liver disease, obliquity of the 
pelvis producing unequal length of the legs, carrying heavy weights on 
one side, and various morbid growths of the chest and abdomen, may 
all produce curvatures. Many cases are found in school children who 
are growing rapidly, and whose muscular strength and development do 
not keep pace with their growth. Unilateral atrophy of the muscles, 
due to central changes or overuse, may be the cause of deviations of the 
spinal column. Sacro-iliac disease in some instances is a potent factor. 
Thus there may be a great variety of causes productive of the incipiency, 
and the spine being strained or irritated at a single point and in a certain 
way gradually develops a curvature. Every spinal and innominate lesion 
should be considered as a potential cause for a curvature. 

Scoliosis. — This is the most conmion spinal deformity and is char- 
acterized by lateral deviation from the median line. In most cases the 
curve is to the right in the upper dorsal region, with a compensatory 
curve in the opposite direction in the lumbar region. The curve being 
to the right in the majority of cases, is probably due to the fact that most 
people are right-handed. 



The Practice of Osteopathy 97 

Morbid Anatomy. — The vertebrae in the region involved are ro- 
tated so that their spinous processes point toward the concavity of the 
lateral curve. The bodies of the vertebrse on the side next to the con- 
cavity are thinner, due to absorption; the intervertebral discs are made 
thin on the same side by pressure and absorption. The ribs are consid- 
erably distorted, depressed on the concave side and prominent on the 
convex side. The ligaments on the concave side are contracted, and 
stretched on the convex side. The muscles on the concave side are 
more or less contracted, and on the convex side they are stretched, caus- 
ing atrophy and fatty infiltration of their tissues. 

Kyphosis. — This may be a sHght posterior curve really amounting 
to nothing, or it may be a very grave pathological condition as in Pott's 
disease. Therefore it is very necessary that one should make a most 
careful diagnosis (see Pott's disease). 

The most common causes of kyphosis are Pott's disease, rachitis, 
occupation, general weakness, rheumatism and old age. 

In Pott's disease, the posterior curve is characterized by a sharp 
angle, and by the spine being very rigid. This, taken in conjunction 
with the history and other symptoms should be sufficient to enable one 
to make a diagnosis. Radiographic examination should be made. 

The condition of round shoulders, which in time produces marked 
kyphosis, is rarely a habit as it is usually termed. In nearly every case 
it indicates either a weakness of the back muscles or, what is more apt 
to be the cause, a strained posterior condition of the dorsal vertebrae, 
commonly of the lower dorsal region. 

Morbid Anatomy. — In mild cases there is simpl.y a relaxation 
of the Hgaments of the vertebrse and a separation of the laminae and 
spinous processes. In severe forms there may be absorption of the 
anterior portion of the intervertebral discs and the bodies of the verte- 
brae (Pott's disease). 

Lordosis. — This may be a congenital condition, especially when 
occurring in the lumbar region. Anterior curves of the spine are gen- 
eralty found in the lumbar or cervical regions, but occasionally occur 
in the dorsal region, causing the spinal column to be more or less straight, 
and thus weakening the individual. This curve is commonly compensa- 
tory to kyphosis, hip-joint disease and congenital dislocations of the 
hip. 

Treatment of Spinal Curvatures. — The treatment of patho- 
logical curves of the spinal column, by osteopathic methods, has been 
highly satisfactory to both osteopath and patient. The success of the 



98 The Practice of Osteopathy 

osteopath in these cases has been due to his comprehensive and exact 
knowledge of each vertebra, and of the spinal column in general. He 
recognizes curvatures that the ordinary practitioner, and it is safe to 
say the orthopidic speciahst, would not even notice or recognize. On 
account of the highly developed sense of touch of the osteopath, he is 
capable of detecting the slightest deviation of one vertebra from anoth- 
er, and of the spine in general from the normal. Thus by the uniqueness 
and pecuharity of his work he is capable, not only of discovering a curva- 
ture, but also of reducing a curve when found. 

The work consists of, first, relaxing any muscles that may have 
become rigid over the seat of the curve. Then follows a treatment to 
each vertebra involved, by attempting to replace it, and treatment to 
the curve in general by springing it toward its normal position. At each 
treatment effort should be made to accomplish something toward cor- 
recting the spine; too many treatments are given in a "general" wa}^, 
and being unspeciahzed amount to nothing. One must become famihar 
with the exact location of each vertebra involved, to attempt a correction 
of a curvature intelKgently. Upon this one point it is impossible to 
speak too strongly, for a great many treatments have been wasted and 
improvement of cases retarded by not paying enough attention to the 
details of the diagnosis, either from pure slothfulness or from an imper- 
fect conception of osteopathy. Corrective exercises are always of val- 
ue in addition to treatment. 

These remarks refer to incipient and certain moderate curvatures. 
In other cases radical measures (Abbott) should be employed if age and 
conditions permit. Remember, however, that the practitioner in his 
daily work of adjusting the many combinations of rotation and side- 
bending lesions corrects innumerable actual and impending curves. 

Lateral curvature in the dorsal region is undoubtedly the hardest 
to correct on account of the ribs, which compUcate the condition. A 
marked curve in the dorsal region is sure to be accompanied by a dislo- 
cation of the vertebral end of one or more ribs. Treat each distinct 
lesion separately, follow by general stretching, replacing and molding 
of the tissues. A good method to stretch tissues and adjust a moderate 
lateral curve is to utiHze the swing, or in lieu of this have the patient 
stand just at arm's length from the wall with concave side toward the 
wall with straight arm at right angles and palm resting against the wall. 
Stand in front of patient whose feet are firmly on the floor and reach 
around with both hands upon the spine. As the patient sidebends 
toward the wall it tends to correct the deformity, so if the operator co- 



The Practice of Osteopathy 99 

ordinates his adjustment with that lateral movement of the patient, 
precise fulcra can be obtained and a certain, definite correction secured. 
The significance rests with the stretching of tissues and the definite fulcra 
obtained , thereby securing a maximum sidebending and rotation toward 
correction. 

The dislocation of an innominate sometimes complicates mat- 
ters, but is a simple point to remedy, and should not be overlooked. 

The correction of a curvature presents a special study to the osteo- 
path, whether it be scoliosis, kyphosis or lordosis, and special rules can- 
not be laid down for treatment. Cases of rare occurrence are what might 
be termed "symmetrical" curves; i. e., no vertebra presents separately a 
marked lesion, the column on the whole being simply bowed. Such 
cases can be treated by springing back the spinal column, and by the 
use of methodical exercises. Unfortunately most curvatures are char- 
acterized by various lesions between the vertebrae, and thus each lesion 
requires special work. 

In simple curves the use of braces, jackets, and the various me- 
chanical appliances are of very little use to the osteopath, in fact, more 
harmful on the whole, than beneficial. Naturally they would apply to 
a "symmetrical" curve, or where the patient is too weak to sit or walk, 
but they can be of very little use to the average patient, in place of cor- 
rect osteopathic treatment. Mechanical appliances confine the move- 
ments of the patient, interfere with the development of the muscles, and 
impinge to a greater or less extent the spinal nerves. Due attention to 
hygienic surroundings and diet are certainly of aid. Proper exercises 
and occupation for the sufferer should be advised. Special care should 
be taken in examining (radiographic) for infectious lesions (arthritis). 

Straight Spine is a term used particularly by osteopaths for a 
condition seldom recognized by orthopedic surgeons. The following 
is from H. W. Forbes^: Straight spine is "a, departure from the normal 
in the conformation of the chest; characterized anatomically by bilateral 
diminution in size, decrease in the antero-posterior diameter, relative 
increase in the transverse diameter and flattening of the anterior and 
posterior walls; characterized clinically by diminution of respiratory 
capacity, lowered lung and heart resistance, impaired general nutrition 
and predisposition to neurosis. 

"Of the many possible manipulations that may be used to Hft and 
overcome the morbid bend of the ribs I will attempt the description of 
])utone. 

1. .Journal of the American Osteopathic Association, 



100 The Practice of Osteopathy 

"Relax the musculature of the back and chest. Rotate, flex and 
extend the dorsal spine. Examine all the ribs on each side and loosen 
an}^ that do not move freely. Having done this, the patient is prepared 
for the specific treatment. Have the patient sit on a stool and lean for- 
ward on a table. Have him separate the elbows, flex the fore-arms, place 
one hand over the other and his forehead on the hands. Tell him to 
relax all the muscles of the shoulders and arms and to breathe deeply 
without using the muscles. After a few trials he is able to fully expand 
his chest without contracting the muscles connecting the upper extremity 
with the trunk. The physician then takes a position at side (either 
side) of the patient and places the weight of his trunk on the ribs of the 
side he is on, a little external to their angles. He passes his arms around 
the patient's bod}!-; the arms passing across the front of the chest are 
carried around far enough to allow the hand to be placed on the ribs just 
external to their angles. The other hand is placed on the top of this one. 
In this position the physician's body on one side, and his hands on the op- 
posite, occupy similar positions. The patient is now told to inspire deeply 
and at the same time to relax the shoulder muscles, as before instructed. 
As the chest expands drop the weight of the trunk on one side and make 
pressure forward (forward meaning toward the anterior surface of pa- 
tient's body) with the hands on the other side. This Ufts the ribs to a 
greater extent than the patient unassisted could lift them. At the end 
of inspiration and during the first third of expiration the chest is com- 
pressed laterally. The compressing force, if appUed correctly, will fix 
the ribs in a position of less obliquity and will also correct the increased 
lateral bending of them. The dorsal spine becomes more convex poster- 
iorly at the moment of lateral compression of the thorax, if correctly 
made. Great force should not be used at the beginning. Repeat the 
manipulation five to twenty times each treatment. Give treatment 
three times a week. A similar movement may be given on the table. 

"The greater number of flat chests in patients under thirty years 
of age may. be corrected. If the patient is above thirty, although com- 
plete correction may not always be accomplished, the results are satis- 
factor^^ Two to six mouths treatment is required." 

A ^'typhoid spine" comes as a sequel to typhoid fever. There 
is constant pain, tenderness along the lumbar region and rise of tempera- 
ture. The pain is generally increased when the spine is moved forward 
or sidewise. Such a condition is clearly understood by the osteopath. 
There are always found distinct vertebral lesions along the region that is 
tender on pressure. In fact these very lesions may have been the pre- 



The Peactice of Osteopathy 101 

disposing cause of the attack of typhoid fever. The treatment is rest 
and the indicated manipulation to correct the derangements. It is of 
great interest to note that where the typhoid patient is treated osteo- 
pathically the condition just described seldom results. Observations 
by C. M. T. Hulett confirm this statement. 

The Neurotic Spine may be the result of injury but the subject 
is usually of a nervous, neurasthenic type. It occurs from the age of 
puberty to adult, much more often in females than males. 

The patient has dull pain in the back of the neck or in the lumbar 
or sacral region, complains of a constant tired feeHng and often of a 
sharp neuralgic pain in certain parts of the spine. Generally there is 
a drooping posture in the upper dorsal with shoulders thrown forward, 
which is a sign of weakness. There. is extreme tenderness along the 
spine and usually the pain is confined to the sensitive places. 

Treatment consists of a constitutional toning up, and increasing 
muscular strength through judicious exercise. The posterior curve may 
be pushed toward the median line by laying the patient on the face ; 
also with the knee in the back and the flat of both hands on the sternal 
ends raise the ribs; or by the arms making use of the pectoral muscles 
accomplish the same result. Deep breathing is also effective. Relief 
can usually be given and a cure wiU depend upon the patient's general 
condition. 

The Hysterical Spine is usually considered the same as the neurotic 
spine, but there are many cases which have the sensitive spine without 
being hysterical. There is more deformity usually present, particularly 
in the lumbar region. Probably there will be a history of some injury. 

The treatment is to correct the curvature and build up the general 
health. These conditions are stubborn and progress is slow. In both 
the neurotic and hysterical spines the ligaments of certain areas will be 
found atonied and relaxed. This is especially noticed upon attempting 
to spring a group of vertebrae when all of a sudden the section relaxes. 
In either of these spines the lesions wiU irritate or obstruct nervous courses, 
produce venous stagnation or arterial starvation, and disturb lymph 
channels. H. F. Goetz has observed that in functional nervous diseases 
the dorsal spine is flat, while in visceral displacement the dorso-lumbar 
spine is posterior. 

The Spine of the Aged wherein is found stooped shoulders and a 
rigid spinal structure, can be distinctly improved by slow, cautious 
traction. This tones weakened muscles, releases contractures, separates 
the compressed intervertebral discs, and definitely tones the viscera. 
Careful work is imperative. 



102 The Practice of Osteopathy 



POTT'S DISEASE 

An article on Pott's disease does not really come within the prov- 
ince of a practice of medicine. Still it will be acceptable to the practitioners 
and students of osteopathy, as one of the objects of osteopathic work is 
to improve, not only medical and obstetrical practice, but also surgical 
practice, and besides the osteopath will have many cases of spondylitis 
to treat. "Pott's disease, or caries of vertebral bodies, was first de- 
scribed by Percival Pott in 1779. It consists of a destructive ostitis 
affecting the spongy tissue of one or more of the bodies of the vertebrae. 
The ostitis is tuberculous, and is similar in character to tubercular ostitis 
seen in the epiphyses of the long bones. Owing to the superincumbent 
weight of the head and shoulders pressing upon the carious vertebral 
bodies, the spine and trunk become peculiarly and characteristically dis- 
torted. The morbid process is Umited, as a rule, to the bodies; the trans- 
verse, articular, and spinous processes are rarely primarily affected." 
(Park). 

The first consideration in the treatment of Pott's disease is rest. 
If the disease is a progressive one, rest in bed in the recumbent position 
is necessary. Naturally, the object of the treatment is to secure resolu- 
tion of the tubercular ostitis as soon as possible. To do this, careful 
manipulative treatment should be applied to the diseased vertebrae. 
The treatment must not be harsh, for there would be danger of greater 
irritation to the parts, and possibly infected particles from the destroyed 
tissue might gain entrance to the vascular system. The osteopath must 
be extremely careful how he manipulates the spinal column in Pott's 
disease. The object of the manipulation is not primarily to overcome 
the deformity, as some may think such an act possible, but to separate 
the vertebrae enough to allow a freedom of the circulation, and to remove 
impingements of the nerve tissue. It is impossible to overcome the 
deformity to any extent when part of the body of the vertebra is de- 
stroyed ; but if one could treat the case at the incipiency, most probably 
deformity would be prevented. There is another danger in treating 
cases too severely, and that is causing exhaustion of the patient. Treat 
the spinal column not only to separate each articulation slightl}^, but to 
carefully crowd the diseased vertebrae toward their normal position. 
When the disease is in the dorsal region, considerable attention has to 
be paid to the ribs, as they are invariably involved when the spinal 
curvature is great. Hence it is necessary to treal each rib separately, 



The Practice of Osteopathy 103 

and try to correct them at least, and remove any obstruction to nerve 
fibres or vessels that may be found. One of the strongest arguments 
against the indiscriminate use of braces, jackets and various mechanical 
appliances in spinal deformities, is that they tend to straighten the spine, 
by simply crowding the vertebrse and ribs as a whole into place, besides 
interfering with the cutaneous circulation. The osteopath should realize 
that each vertebra and rib has to receive special treatment, in order to 
correct the spinal column, and that mechanically exerting pressure upon 
all the vertebrse at one time tends to lock the vertebrse and ribs all the 
more securely. It is like trying to correct a certain subdislocation of 
the cervical vertebrse by pulling and twisting the neck instead of applying 
specific treatment — the lesion is all the more firmly fastened. Young, in 
his Surgery, makes this observation: "Like chronic abscess or chronic 
bone disease, this affection has its origin in the fact that the tissues of 
the anterior parts of the bodies of the vertebrse have been partly deprived 
of their nutrition because of luxated ribs or subluxated or twisted verte- 
brte." 

After the tissue destruction has been limited, and the deformity 
corrected as much as can be, an ankylosis should be secured if possible. 
Promotion of ankylosis depends altogether upon the preceding treat- 
ment — rest and an improved nutrition of the parts. A truss or brace, if 
correctly applied, is often beneficial in such cases. The treatment of 
spinal abscesses is entirely in accordance with surgical treatment. 

In all cases the general health of the patient has to be well taken care 
of. The osteopath must not be over zealous for quick results. It takes 
many months to perform a cure; however, there is always a tendency 
toward a cure. Treatment of the spinal muscles and of the limbs, and 
pure air, sunhght, massage and good food are very necessary. 



104 The Practice of Osteopathy 

SPRAINS AND FRACTURES 

Sprains 

The osteopath is often called upon to treat sprains of various sections 
of the body as well as to relieve after effects of fractures and restore func- 
tion to the part. The osteopathic treatment is very effectual; therefore, 
an outline of the purpose and method is given. 

Sprain is defined by Borland as ''the wrenching of a joint with par- 
tial rupture or other injury of its attachments, and without luxation of 
bones. " From an osteopathic viewpoint the above definition is not fully 
explanatory, for there is in most cases a partial luxation of the bones. The 
most common cause of a sprain becoming chronic is the presence of partial 
bony displacements. Rupture of tissues may be the cause of a chronic 
state but is not nearly so frequent as the bony dislocation. In most 
sprains, the wrenching causes a displacement of the bony tissues, which 
may or may not return to normal position and relation. The function 
of the muscles is not primarily to hold the bones in place; this is left to 
the Hgaments, so when a wrench of a joint is so severe as to cause rupture 
of muscles or tearing of ligaments, partial luxation of the bones is almost 
certain to follow; and even where such damage does not occur a change in 
the relation of the bones is a frequent occurrence. 

Unless a sprain can be seen very early it may be difficult to detect 
just what has happened; whether it rests with a rupture of the areolar 
and connective tissues, a displaced cartilage, tendon, or bone, a torn 
hgament, or ruptured muscle. Hemorrhage and swelling take place so 
rapidly that no time should be lost in critically examining the joint. 
When in doubt as to the structural disturbances, particularly in acute 
cases if there is a possibility of a fracture, and in chronic cases any sup- 
position that tubercular involvement is present, have a radiographic 
examination. 

There is comparatively Httle to be found in medical literature rela- 
tive to the pathology of sprains. Probably Moullin in his excellent 
monograph on Sprains has given as good an outline as can be found' . 
He says that ''generally speaking, the tissues on one side of a joint are 
overstretched and torn; those on the other compressed and crushed to- 
gether; but there is always so much twisting, and such a difference in the 
strength and power of resistance of various structures, that unless the 
part is examined with the greatest care it is almost impossible to say 
1. See also Jones' latest work, Injuries to Joints. 



The Practice of Osteopathy 105 

what actually has given way." Hemorrhage due to torn vessels is the 
cause of most of the swelling within the first few hours. Later on, there 
is considerable lymph mixed with the blood. There is not only extra- 
vasation of blood into the surrounding tissues but also into the synovial 
wall and cavit}^ This causes considerable irritation and pain owing to 
the roughening of the membrane, and the joint becomes inflexible. And 
if the joint or any strained tissue is kept too long at rest the mass be- 
comes organized and is the cause of much discomfort and annoyance. 

Similar changes may occur in the bursae due to the extravasated 
blood. Strong ligaments may be torn across, but not frequently. The 
tear is usually a separation from the bone. Occasionally interosseous 
ligaments, as for instance in the knee, may be injured. 

The muscles may be severely torn, but more often they are ''hurt 
by their own sudden and spasmodic effort at recovery than by anything 
else." In a few cases the tendons and muscles will be found bruised, 
lacerated, and dislocated. 

The veins occasionally rupture and thus results more or less effusion, 
so that rigidity and edema may persist for a long time. The bones are 
very frequently damaged. This may be a simple bruising of the tissue 
but more often, as osteopathic diagnosis shows, there is partial displace- 
ment of the bony structure. 

A point of great importance that every experienced osteopath will 
agree to is the following from Moullin: "Diseases of the spine, hip, and 
other joints in children may be due, in great measure, to some constitu- 
tional taint, though it is open to question whether the influence of this is 
not overrated; but it is quite certain that the immediate starting-point 
in nine cases out of ten is some chance sprain, often so sHght as scarcely 
to have been noticed at the time." 

Before treating a sprain there are one or two points the osteopath 
should carefully note: first, that there is no complicative fracture ; 
second, in children that there is not an epiphysial separation; and, third, 
note peculiarities of a constitutional character that would complicate 
matters. Whatever is done, always give the patient the benefit of the 
doubt. 

If the patient can be seen early, before swelHng has reached the 
maximum, many times a very quick cure can be secured. Do not at 
once put the part at rest and apply cold, but examine the sprain most 
carefully and thoroughly and readjust first of all any bony defects; then 
replace the softer tissues if displaced, and next relax contractions; follow 
this by fight massage and passive movements to reduce and combat 



106 The Practice of Osteopathy 

hemorrhage and swelling. This treatment alone in a fair percentage of 
cases will be all that is necessary provided frequent subsequent treat- 
ments of massage and passive movements are continued to reduce and 
counteract inflammation and to prevent rigidity and stiffness of the 
softer tissues. Where the osteopathic treatment is distinctly indicated 
is in the readjustive manipulation. This is the reason why the treat- 
ment is so efficacious, and the patient is cured in a fraction of the usual 
time, and few sprains result in complications and become chronic. In 
sprains that have become chronic there will be found almost invariably 
some osseous tissue slightly displaced. After correcting this, apply 
careful and thorough manipulation and massage and movements to 
break up adhesions, to remove effusions and extravasations, to relax 
muscles, and to promote normal circulation. Care should be taken 
that there are no displaced cartilages, ligaments, tendons, or muscles. 

It is well to keep in mind that the osteopathic readjustive manipu- 
lation is not an exercise or movement, but definite, specific correction 
of the tissues anatomically. Do not treat the displacement b}'' any 
general "pommelUng, " but apply the mechanical principles indicated as 
in any dislocation. This will mean much to the patient in more ways 
than one, and especially so should the sprain be so severe and compli- 
cated as to demand anesthesia for correction. 

There is no objection to the employment of cold and heat; in fact, 
both are beneficial. Cold to prevent extravasation and swelling, and heat 
to remove and reUeve the same, is a sound and practical method. But 
do not apply a wet bandage. Pouring cold water over the sprain is the 
best method; even better than immersing the part. An ice bag is 
another good way to apply cold. When the skin begins to look blanched 
and dull the maximum amount of benefit has been secured. Heat at 
the very first may be employed instead of cold, for it has a tendency to 
prevent bleeding and inflammation, but the temperature of the appli- 
cation must be hot as can be borne or else the desired effect will not be 
obtained. Later on to reheve pain and rigidity, and to relax the muscles 
so that a better circulation will be secured, moderate heat will be bene- 
ficial. Then the application of heat and cold alternately will be of ser- 
vice, employed as a douche for a tonic effect, when the part is weak, in- 
a,ctive, and powerless after the elapse of several days. It should always 
be remembered that the emplojonent of heat and cold is only of temporary 
benefit, so if used too long opposite effects to those desired will result. 

Bandaging the sprain may be helpful, but not alwaj^s. Great care 
should be taken as to how pressure is apphed. Bandaging from periphery 



The Practice of Osteopathy 107 

toward the trunk, seeing that the bandage is smooth, and padding all 
depressions so that the bandage does not touch bony prominences only, 
are necessary. Unless the bandage is applied so that an even pressure is 
secured, the material used not too warm, and the bandage attended to 
each day, the effectiveness will amount to but little. 

Next, do not make the mistake of resting the injured joint too much. 
The function of a joint is movement, and it has been observed that pro- 
longed rest of a healthy joint may result in rigidity, stiffness, and dis- 
tension of the soft part, and even serious organic changes in the Uga- 
ments, synovial membrane, and cartilages have occurred. Consequently 
continued passive movements should be kept up from the inception of 
the injury, although it must not be carried to extremes so that inflam- 
mation, hemorrhage, or laceration will be aggravated. Moullin says: 
"As a rule, passive movement may be commenced from the second 
day with the certainty of preventing adhesions, and without the least 
fear. " Osteopathically, with due attention to readjustive manipulation, 
and care as to correct position and rest, passive motion will be allowable 
usually from the first day. 

There is much corroborative evidence in current medical literature 
that bears in a general way upon part of the foregoing. The Inter- 
national Text Book of Surgery says: "Massage should begin early, 
in order to avoid, as far as possible, weakness of the muscles, and to 
ensure security to the position of the joints by the retention of a proper 
tone in them;" besides, early movement tends to reduce the effusion into 
the tendon-sheaths around the articulation, which in some cases, par- 
ticularly the ankle and wrist, may be a very prominent feature. The 
Reference Hand Book of the Medical Sciences voices the same opinion; 
and Mumford is referred to as follows: "Immobilization for more than 
a few days, as under the older methods, is objectionable because adhesions 
are apt to form, thus causing impairment of function, and because when 
there is a tubercular taint, proper conditions for a localized tuberculosis 
are established." Among other statements Holder Sneve in the Journal 
of the American Medical Association of June 1, 1901, says: "Immobiliza- 
tion of muscles is not rest. On the contrary, in all sprains the muscles 
should have passive exercise the first few hours and days, and active exer- 
cise after that. In the majority of cases active exercise should be insti- 
tuted from the beginning. The plaster cast should not be used at all, 
even in cases where we have a fracture, unless it be impossible to main- 
tain a proper position of the joint. "^ 

1. See also Wharton Hood, Sprains and Fractures. 



108 The Practice of Osteopathy 

Again quotation is made from Moullin. These quotations are 
taken from the chapters on Manipulation and Massage. It will be ob- 
served he makes a distinction between the two methods. And the os- 
teopath should carefully keep in mind not only the difference between 
the two, but beyond these the more fundamental treatment, readjust- 
ment. The characteristic feature of osteopathy is anatomical readjust- 
ment, and this in sprains should be supplemented by massage (super- 
ficial work), and also manipulation (deep and more or less forcible work) 
in order to remove stiffness, rigidity, and fibrous ankylosis. 

The following is relative to forcible manipulation: ''Manipulation 
is much more useful than division; it can be employed for such a variety 
of purposes. In the early stages it prevents the occurrence of stiffness 
or the formation of adhesions. Later, when the swelling and heat have 
disappeared, it is no less successful in restoring freedom and ease of move- 
ment, and afterward, when all mechanical obstructions have been cleared 
away bj^ its use, it is one of the most effectual methods known for bring- 
ing back the circulation and nutrition of the part, and giving again to 
the muscles and nerves the energy which has so long been wanting 

"To carry this out effectively two things are needed beyond aU 
others. The one is a sense of touch so delicate that it can appreciate 
the least resistance or irregularity of movement; the other an accurate 
knowledge, not merely of the ordinary anatomy of the part, but of the 
different degrees of tension that fall on the ligaments in every position 
of the hmb. 

"Each joint requires a different kind of manipulation according to 
its construction 

"There should be no jerking. The movements must be vigorous 
and forcible, but perfectly smooth; and they must be carried out thor- 
oughly, the joint being moved to its full extent in all directions that are 
natm-al to it. Each land of action should be combined successively with 
the rest, one by one, so that the tension may fall in turn upon all the 
different parts of the capsule. 

"Movements which are especially restricted or painful, of course 
require most attention, but the others, though they may not be affected 
to the same extent, are not to be neglected. It sometimes happens if 
these are dealt with first, that a considerable proportion of the main 
obstruction is cleared away, as it were, by side attacks, so that when its 
turn comes it yields more readily than it otherwise would. 

"Recent slight adhesions give away at once without a sound, though 
the sensation is generally conveyed to the hand. When they are older 



The Practice of Osteopathy 109 

the noise may be as loud and clear as when a bone is broken 

''The after treatment of these cases (cases where there has been 
tearing and breaking of adhesions) should be in all respects the same as 
that of a recent sprain, only if passive motion at an early date is ad- 
visable to prevent the occurrence of stiffness in the one, it is absolutely 
necessary in the other. " 

The following pertains to massage of sprains: ''Massage, in the 
strict sense of the term, is a great deal more efficacious, especially with 
older sprains. Its action is not hmited to the skin and superficial struc- 
tures. These undergo immense changes, it is true; they become softer 
and finer while under manipulation; their strength and elasticity increase, 
the extreme tenderness diminishes, and the natural appearance and 
texture return. The surface loses its dry, harsh character and becomes 
warm and moist again; the livid bluish color gives away to a brighter 
hue, and the deeper layers of fibrous tissue yield and stretch, so that the 
hide-bound, shrunken condition that is often present after long disuse 
gradually passes off. But the good effect is not by any means Hmited 
to, or even most conspicuously shown by, this. When properly carried 
out, massage exerts a simultaneous influence on muscles, nerves, and 
vessels; in fact, on all the tissues within its reach. 

"The circulation is the first thing to feel its power. It has already 
been explained how, after prolonged rest, the blood, as it were, Hes almost 
stagnant in the tissues, slowly circulating through them, and neither 
giving them sufficient for their nutrition, nor removing from them the 
waste products of their action. This is changed at once. The life of 
the part is quickened. The veins and absorbents are emptied first, and 
the fluid they contain driven out into the heart, which fiUs more rapidly, 
and contracts more vigorously and firmly. Then the pressure falls in 
the smaller vessels, and the tiny irregular spaces, full of tymph, which 
extend in all directions through the tissues. These, in their turn, are 
compressed and mechanically emptied, their contents being driven on 
into the empty vessels, from which any backward flow is prevented by 
the valves. The circulation becomes more rapid; nutrition is carried 
on with greater energy, and the actual amount of the blood in the tissues 
at any one time so much increased that they become full and soft to the 
touch and regain the even and rounded contour of active health 

"It is most essential to commence as gradually and as gently as 
possible, working on the deeper tissues only after the more superficial 
ones have become thoroughly accustomed, and have been unloaded of 
their surplus fluid. The skin, the soft sub-cutaneous tissue, the muscles, 



110 The Practice of Osteopathy 

and the deeper laj'ers, must all be worked in turn. Nor should the 
manipulation be confined to the injured part. In a sprain of any stand- 
ing, the whole of the limb is affected more or less. It is usually better to 
devote attention fii'st to the parts nearer the trunk than to deal with 
those around the injured area, and only afterward, when the circulation 
is thoroughly re-estabhshed, to manipulate the joint itself. 

"The tendency is to make the sittings last too long. Deep manipu- 
lation itself rarely requires more than five minutes; but in dealing 
with a recent injury it may be ad^dsable to spend a longer time than 
this over the friction and other preparatory measures, so that a quarter 
of an hour soon passes by. When the tenderness is very great, and the 
amount of swelling excessive, much longer than this maj^ be necessary, 
but short, frequently repeated sittings are of greater benefit than one 
long one. A skillful operator, too, will often effect more in a few minutes 
than an ordinarj^ rubber will in as many sittings. " 

A summar}' of the general treatments of sprains would be as follows: 

1. Readjustment of parts and removal of obstructions. Osteopathy 
is especially adapted in these cases, for two of the primal therapeutic 
factors in all cases from an osteopathic viewpoint are to re-adjust the ana- 
tomical and to remove obstructions. One should constantly keep in 
mind, "a temporary displacement followed immediately by a return to 
place, constitutes a sprain." The osteopath often finds that a perfect 
returning does not take place, and even remote lesions may affect a joint. 

2. Manipulation, and massage of soft tissues, to restore circulation 
and to prevent and remove debris from rupture of vessels and inflamma- 
tory products. 

3. The employment of cold, heat and pressure, and a certain amount 
of rest. 

4. Anatomical regfdjustment and manipulation in chronic cases to 
break up adhesions, remove exudates, overcome the organized products 
of inflammation, and cure synovitis. 

5. ]\Iovements both passive and active to stimulate and exercise 
functions of the joint. 

The Spinal Column. — The osteopath is especially cognizant of 
the fact that many sprains occur to the spinal column. These may 
affect a single joint, or more or less of a section may be involved. The 
bones, ligaments, tendons, muscles, or spinal cord may be found injured. 
Even distant organs, through involvement of the circulation to the cord, 
or through irritation or impingement of spinal nerves and sympathetics, 
are frequently disordered. It is not necessary to go into detailed de- 



The Practice of Osteopathy 111 

scription, for the points bearing upon this will be found under Osteo- 
pathic Diagnosis, Etiology, and Tecnhique, and the general descrip- 
tion will, also, apply. Readjustment, strapping, heat, massage, manipu- 
lation, ironing, stretching of muscles, fomentation, etc., have their 
place. There is no doubt that sprains, strains, ^nd blows to the spinal 
column are the cause of many spinal disorders and consequent visceral 
disturbances. 

The Ribs. — Sprains of the vertebral ends frequently occur, result- 
ing in a partial luxation, stretching of hgaments, contraction of muscles, 
and exudative formation in the joint structures, which often is the cause 
of irritation to the sympathetic nerves. The costal cartilages are fre- 
quently strained, and may so irritate the intercostal nerve as to cause 
considerable pain both locally and reflexly. The treatment is essentially 
one of replacement, and relaxation of the softer tissues. Adhesive strips 
to limit movement due to respiration may be helpful. 

The Innomlnata. — Sprains of the innominata are also commonly 
met with. Besides being a source of discomfort to the patient they 
are an important cause of pelvic disorders and leg affections. Partial 
displacements are the rule, the correction of which gives quick relief. 
Where there is considerable spasm of muscles, examine carefully the 
lumbar alignment. In chronic cases fibrosis of muscles and adhesions 
may compHcate matters. 

The Hip Joint. — Sprains involving the hip joint may be readily 
corrected, and again may be the exciting cause of serious involvement. 
Previous tubercular disease can be aggravated in this manner, or syphilitic 
changes in the joint disturbed. Care should be taken that there are no' 
complicating displacements of the innominata or irritations to the spinal 
nerves. Possibly the hip maj'" be so strained as to cause a twist of the femur 
in the socket and thus simulate a partial dislocation; this, in fact, would 
probably be termed a partial dislocation. Strain of one set of muscles 
about the hip joint is somewhat rare, and spinal lesions may disturb the 
innervation to one set of muscles. In cases of intracapsular fracture 
considerable can be done by careful massage and manipulation after 
union has taken place, to secure greater freedom of movement and 
strength of the limb. Likewise in hip-joint disease, after the disease 
is healed, massage and manipulation will be very beneficial. Care must 
be taken if the treatment causes spasticity of the muscles; this shows the 
treatment is irritative and should be stopped until the spasticity has 
ceased. Where the limb is shortened from either hip-joint disease or 
intracapsular fracture apparent lengthening may be secured by care- 
ful abductive and hypcrcxtcnsive stretching. 



112 The Practice of Osteopathy 

The Knee.— The knee is the most comphcated joint, and sprains 
are apt to be very serious. The usual treatment for sprains is employed. 
Occasionally the semilunar cartilages are displaced and may be a source 
of difficulty in diagnosis; likewise injuries to the patellar tendon and 
lateral Hgaments. Another joint frequent overlooked is the innominate. 
In a mmiber of knee cases that terminate in chi'onic synovitis there will 
be found a displacement of the innominate that is preventing revovery. 
A villous synovitis may arise in strains from faulty posture, especially 
in the obese. Injury to the hip-joint, also, may cause strain or irritation 
at the knee. Occasionally tender points about the knee, especially at 
the inner side, are due to irritation at the hip, or possibly from the spine. 
Referred pain of the knee joint is of frequent occurrence. 

The Ankle and Foot. — The ankle is often sprained. One should 
examine carefully for a possible fracture of the malleolus, and for frac- 
ture of the tibia. There may be a dislocation of the fibula, also a sepa- 
rating of the tibia and fibula at the ankle. The common bony displace- 
ment takes place between the astragalus and os calcis. Then the cuboid 
is frequently displaced, and occasionally the navicular. The treatment 
should first of all be directed to correction of the osseous lesions. The 
arch of the instep may be weakened from the ligamentous strain and be 
an immediate step in the production of flat loot. Teall is of the opinion 
that lumbar and innominate displacement are common predisposing 
causes. Faulty position of the foot in walking may be an underljdng 
factor. 

Bunions result from a malposition of the joint. Morton's disease 
due to a pinching of the metatarsal nerve will often yield to osteopathic 
treatment alone. There is generally displacement of the metatarsal bone. 
A pad worn directly under the painful point will be of benefit. In many 
of the local neuralgias, some anatomical displacement will be found as 
the exciting cause. Hammer-toe if not comphcated with gout, rhemna- 
tism, etc., will yield to treatment if kept at persistentlj^ otherwise sur- 
gical interference will be necessary. 

Likewise various deformities of the foot and resulting neuralgias 
ma}' be traced to local sprains, ill-fitting shoes, or anatomical malad- 
justments higher up of such a character as to affect the pedal circulation. 

Flat Foot 

Flat foot or weak foot is one of the common disorders that the os- 
teopath is constantly called upon to treat. In the first place the patient 
should be taught to walk correctly. The feet should be parallel in walk- 



The Practice of Osteopathy 113 

ing so that the weakened muscles may be developed and strengthened. 
This will be dijB&cult at first, but recovery depends upon this important 
point. In addition to this, special exercises, Hke turning the toes under 
and tip toe exercises, should be persisted in for a few minutes two or 
three times daily. Upon the other hand, do not overdo the exercises 
but always carry them to a point of fatigue. These two features, walk- 
ing correctly and exercising, are essential complementary measures to 
the adjusting treatment. In conjunction with the above, the Scotch 
douche at the end of the day will prove of considerable benefit. 

In the technique work, first make certain that there are no innominate 
or spinal lesions that bear upon the circulation and innervation of the 
feet. Then frequently faulty walking is due to these lesions. 

In recent cases, simply remolding the arches of the foot will be all 
that is necessary, providing correct walking and foot exercising is main- 
tained. But in the more chronic cases considerable adjusting and re- 
molding of the tissues, bones, ligaments, muscles and fascia, are de- 
manded. Perfect apposition between the astragalus and navicular 
bones, the highest point of the longitudinal arch, should be first secured. 
Attention should also be given the other articulating structures down to 
the metatarsal bones. This re-estabHshes the arch and overcomes the 
everted tendency. Considerable repeated force is often demanded to 
release the fibrotic tissues, but it is the important part of this tech- 
nique. 

With the patient on the table, supine, place your thumb firmly at 
the articulation of the navicular and astragalus. Then with the other 
hand around the metatarsals to be used as a lever in extending, rotating 
and inverting the foot with the fulcrum at the thumb of the first 
hand, spring, thrust and adjust the arch. This requires considerable 
strength and exactness of apphcation. The tissues must give freely 
before the result can be secured. This is often painful to the patient 
but should be continued and repeated to the furthest point of motion 
until recovery is complete. Treat as often as the condition permits. 
Substituting the crotch of the thumb and forefinger or the knee for the 
thumb wiU give added advantage. Follow this with thorough springing 
of the plantar tissues by thumb and fingers. 

If this is kept up with suitable exercises and correct walking, and 
proper shoes (Munson last), excellent results will be obtained in the great 
majority of cases. Same pair of shoes should not be worn two days in 
succession. 

Many times the anterior ai-ch is iin-olvcd, jointly or separately. 



114 The Practice of Osteopathy 

Persistent adjusting and remolding of the arch tissues will secure satis- 
factory results unless the bones are markedly deformed and the weight 
of the body is relatively too great. In this disorder, aside from paying 
special attention to the metatarsal articulations, the great toe requires 
a particular technique. For this grasp the toe firmly, exert traction 
imtil the tissue gives shghtly and rotate it inward, toward the median 
line of the body, on its longitudinal axis. Have the patient frequently 
turn the toes under, or attempt to do it until the exercise can be easily 
accomphshed. 

Do not employ arch supporters except in hopeless cases. They 
simply spUnt the foot and thus further weaken the foot muscles. If the 
above methods are pe'-sistently followed to the point of actual adjust- 
ment, accompanied by releasing of fibrous tissue and actual strength- 
ening of muscles through exercise, a very large percentage of cases will 
recover. In a few cases adhesive strips will be of benefit. 

The Shoulder. — Exclusive of muscular and other strains there 
may be a partial dislocation. In these cases the aci'omial end of the 
clavicle is frequently dislocated, and owing to a general lack of muscular 
tone may be very hard to keep in place. The lower and inner part of 
the capsule is often affected, so that freedom of function is lacking and 
there is considerable pain. This is due to the thinness of the capsule 
and the large amount of soft tissue, so that when the arm hangs at the 
side the tissue is thrown into folds; and being very vascular is easily 
injured, so that the vascular lymph readily organizes and the part be- 
comes stiff and unyielding. It requires patient, laborious treatment to 
break up and absorb this fibrous tissue. Then the long tendon of the 
biceps in some shoulder sprains is dislocated, but rarely. In shoulder 
injuries, examine also, the upper ribs. 

The Elbow. — The elbow is another complicated joint. One should 
be careful that there is no fracture, and in children that there is not 
epiphysial separation. Extending, flexing, pronating and supinat- 
ing the arm will aid much in the diagnosis. Examine well the rotation 
of the radius at the elbow joint, and be positive that the olecranon pro- 
cess drops normally into its fossa at the end of the humerus. 

The Wrist and Hand. — The wrist is another joint commonly 
sprained. Here, also, care should be taken that a fracture does not exist. 
Colle's fracture is frequent. The bursal and tendon sheaths are usually 
markedly involved. The scaphoid and semilunar are apt to be displaced; 
also, the os magnum and the unciform. 

Sprains of the fingers are often met with. Outside of strains to the 



The Practice of Osteopathy 115 

muscles, ligaments, and other tissues the joint is apt to be somewhat im- 
pacted. Traction will correct the latter. Care should be taken that 
a fracture is not present. Dupuytren*s contraction occurs from sprains 
or injuries, as the result of contraction of the fascia. The ring and index 
fingers are members usually affected. In some cases the affection will 
be found in both hands (symmetrical) , and a spinal lesion will be the pre- 
disposing factor. Treatment every day, by straightening the fingers 
and stretching the tissue will at least retard the deformity, but in a num- 
ber of cases surgery will have to be resorted to. 

A ganglion or "weeping sinew" is a swelHng in connection with 
the tendon sheath. It presents a round, firm outline, usually upon the 
back of the wrist. There is generally found a displacement of one or 
more of the wrist bones. If treatment of the joint and tendon sheath 
does not remove the ganglion, surgery may be utihzed. Trigger-finger 
is a rare disorder. There is usually a history of local strain, which prob- 
ably resulted in some thickening of the tendon. Manipulation and 
passive motion if continued will generally give relief. 

Fractures 

ImmobiHzation and rest have been the paramount points with most 
physicians in the treatment of fractures and sprains. They have claimed 
that a sprain should be manipulated but rarely, much less a fractured 
bone. Rest, quiet, and fixation of an injured joint or bone have been 
rules that should not be violated under any consideration. In cases of 
sprain the great cry has been to let the joint alone for fear of spreading a 
possible tubercular infection. It is weU to recaU Mumford's state- 
ment that if immobihzation is too long continued, should there be a 
tubercular taint, proper conditions for a locaHzed tuberculosis is estab- 
Hshed. And still a word of caution here, that an osteopath should not 
be over zealous and should carefully weigh all possible factors, both local 
and constitutional, may not be amiss. In previous tubercular, syphilitic, 
and other diseased states discretion should be employed. 

Reducing rest and immobihzation to a minimum means much to 
the patient, not only in the loss of valuable time but in annoying and 
serious after effects. Many cases of sprains and fractures come to the 
osteopath. In sprains that have become chronic through too much rest 
of the part and improper treatment, almost invariably there is found 
displacements of bone and adhesions that should never have existed; 
then has followed organized exudates and chronic synovitis. In frac- 
tures and even in complete dislocations the osteopath continually ob- 



116 The Practice of Osteopathy 

serves that too much rest has been given the part, resisting in unnecessarj' 
adhesions, contractions, atrophy of muscles, and impairment of func- 
tion. Treatment ahnost always cures the condition, or at least mater- 
ially relieves. How much better if the proper treatment had been first 
instituted and thus a large percentage of cases prevented from becoming 
chronic. 

Of particular interest to the osteopath is the paper prepared by Eis- 
endrath on "Early Massage and Movements in the Treatment of Frac- 
tures and Sprains, " and the discussion that followed before the Chicago 
Medical Society. The Illinois Medical Journal, December, 1903, con- 
tains a report. 

Eisendrath said in part: ''The former routine of immobilizing all 
fractures and the adjacent joints for a period of four to six weeks must, 
I feel, be subject to slight modification in the Hght of recent experience, 
and it shall be the aim of this paper to show what these changes are. 
When we are called to a case of fracture, it should be one's first duty 
after its reduction to consider how can I best aid the patient in recovering 
the usefulness of his or her Hmbs? Can we shorten the long convales- 
cence with its resultant loss of valuable time and earning capacity? How 
can we most rapidly restore to the hmb its normal joint functions and. 
prevent an atrophy of muscles and an ankylosis which will require many 
months to overcome? 

"The use of massage and of active and passive movements in the 
treatment of fractures and of severe sprains has been gradually gaining 
in the number of its advocates through the writings of Lucas-Champion- 
niere of Paris. We owe him a great debt for calling the attention of the 
profession to the employment of these methods in order to prevent 
atrophy and ankylosis as well as to promote healing 

"Before taking up my subject in detail permit me to recall a few 
sahent points in the surgical pathology of fracture. Soon after the in- 
jury the blood clot around and between the ends of the fragments is 
absorbed and replaced by a jelly-like mass of young connective tissue 
cells called the callus. It corresponds to the solder which the plumber 
places over the ends of two pipes he desires to join. Bone begins to form 
at the periphery of the callus about the tenth day and advances toward 
the center rapidly, forming a ring of bone around the ends of the frag- 
ments so that by the end of the third week there is but slight abnormal 
motion at the point of fracture (exception to this is the femur). This 
entirely disappears by the end of the fourth week, especially in young 
people, and the union is firm. In the case of the femur it requires six or 



The Practice of Osteopathy 117 

eight weeks. The greater the displacement of the ends of the fragment, 
the larger the callus and the slower the healing of the fracture. 

"During these changes (callus formation) the muscles which supply 
the immobilized joints atrophy and/ the circulation in the skin and neigh- 
boring tissues is sluggish, resulting in swelling, etc., of the Hmb. The 
enforced rest causes more or less fluid l^o accumulate in the tendon sheaths 
and joints. This becomes organized and results in fibrous ankylosis of 
the joints and great impediment to the free action of the tendons within 
their sheaths. It is this atrophy, fibrous ankylosis and tenovaginitis which 
interfere with the restoration of the normal functions of the hmb 

''Can we decrease the amount of wasting of muscles and control 
the stiffness of joints and tendons after fractures? 

"It is the belief of the writer, based on a large experience, that the 
earher use of massage, active and passive motions, will to a great extent 
ehminate the above conditions, which retard convalescence and in some 
cases cause permanent disability. 

"Massage of an injured limb increases the amount of blood supphed 
to it, promotes the absorption of the swelling and prevents atrophy of 
muscles. In the case of a joint injury the exudate rapidly disappears 
and the articular surfaces can be again approximated so that movement 
is faciUtated. By the cautious use of active and passive movements, 
either with or without the aid of apparatus, the normal functions of a 
joint can be rapidly restored 

"The active and passive movements of the limbs can be carried out 
immediately after the massage, but should only be permitted for a period 
of five minutes at first and the time then gradually increased. When 
a severe sprain, say the elbow or ankle, is first massaged, the pain seems 
to be almost unbearable, but this discomfort as well as the swelling rap- 
idly disappears, and it is surprising to those who have never appHed this 
treatment how quickly the normal function of the joint reappears. 
The same appHes to the synovitis which accompanies fractures in close 
proximity or even into joints." 

The rehef given these cases by massage, movements and manipula- 
tions by the osteopath is a daily experience, and results to him are not 
surprising. Then in addition to what the surgeon would do, the osteo- 
path apphes his principles of careful detail readjustment. 

Eisendrath continues his paper by referring to the principal varieties 
of fractures and giving the treatment for each. He says that if correct 
treatment is carried out with proper massage and movements in fractures 
of one or both bones of the leg, the patient will be at work in six or seven 



118 The Practice of Osteopathy 

weeks instead of three or four months, that in Colle's fracture some sur- 
geons do not employ a spKnt, and that in fractures of the olecranon, 
massage from the first week on is of the greatest use. This part is very 
interesting but space forbids giving it. 

He then concludes his article with citation of several very interest- 
ing cases of fractures and severe sprains. These cases are exceptionally 
interesting to the osteopath, but still the same good treatment and re- 
sults are duphcated every day in the osteopathic school. 

The doctor's contraindications to the use of earty massage in frac- 
tures or sprains are the following: 

''1. Tendency to displacement of fragments in oblique fractures. 
Under such conditions it is best not to begin either massage or move- 
ments until the union is firm (fourth to fifth week). 

"2. In compound fractures until the wound is healed. 

"3. Whenever the condition of the skin is such as to permit of in- 
fection; for example, the presence of blebs, or extensive abrasions. 

"4. The presence of fragments which project but do not penetrate 
the skin. " 

His conclusions are : 

" 1. Massage, active and passive motions prevent atrophy of muscles, 
tenovaginitis and ankylosis so frequently accompanying and following 
fractures, especially those close to the shoulder, elbow, wrist, knee and 
ankle joints. 

"2. The}^ give far better results than complete immobiUzation in 
the majority of fractures." 

In the discussion that followed Henrotin said that for some time, 
"I have never put a restraining apparatus of any kind, nor have I used 
any lotions on any sprain, no matter how severe 

"It has taken many years to bring this subject before the profession. 
It is a method that is absolutely effective as regards sprains and some 
forms of fractures. I have treated several hundred such cases with the 
greatest success." He also said that, "In treating an inflamed joint it 
is improper to use a restraining apparatus of any kind. I consider that 
the plaster cast is the bane of all inflamed joints unless there is a spe- 
cific form of infection, a traumatic condition." Neither does he be- 
heve that an inflamed joint should be put at rest. He says the patient 
is a good judge as to the amount of quiet the joint needs. He has treated 
Colle's fractures and fractured clavicles without bandages or apparatus. 

To sum up, the osteopathic procedure in the treatment of fractures 
would be as follows: 



The Practice of Osteopathy 119 

1. Immobilization in those cases especially demanding it, from the 
character of the fracture, until formation assures sohd and firm union. 

2. Manipulation and massage and movements of parts at an early 
period, compatible with the above, to render soft tissues pliable, to re- 
move stiffness and adhesions, to restore a normal circulation, and to 
exercise and function the parts. 

3. In cases of laceration of soft tissues, abrasions, etc., great care 
should be taken so as not to infect the parts. 

4. Great care should be taken where fracture is compound, and 
where fragments exist. 

5. In all cases, both acute and chronic, critically examine for slight 
anatomical deviations locally and remotely. 

In dislocations the fundamentals of the above are apphcable. Do 
not let chronic stiffness, or rigidity, adhesions, or synovitis supervene 
if possible to prevent. 

An important consideration in all cases of sprains, fractures, and 
dislocations that become chronic is the probable effect upon dependent 
tissues by way of nerve impairment and vascular obstruction; for ex- 
amples, the sprained back may readity impair organic life, the fractured 
elbow prevent use of the arm, the injured leg predispose to flat-foot. 
(See J. B. Little John — Osteopathic Surgery, including Treatment of 
Fractures, Journal of the American Osteopathic Association, Nov., 1905.) 



120 The Practice of Osteopathy 

POSTURAL DEFECTS 

A postural defect is any abnormal position, congenital or acquired, 
of the body, assumed in sitting, standing or walldng. This leads to 
a symmetrical development, causes structural changes, and as a sequel, 
disturbance of function and organic hfe results. 

Defects in posture are of very common occurrence. A perfect pos- 
ture, in fact, is somewhat rare. Considerable is being accomplished, 
especially of late years, by the laity through various physical methods 
and exercises to correct the many defects of position in sitting, stand- 
ing and walking. The originators of the many so termed systems of 
exercises have gone so far as to even advertise to cure various diseases 
of the body as well as attempting to improve the normal tissues and 
structure. 

Exercises, undoubtedly, have their place, particularly in the Ufe 
of those of sedentary habits. Most of us do not exercise enough, neither 
do we as a rule get enough fresh air and pure water. But there are many 
defects of the anatomical that mere gymnastics can not adjust. And 
there are still other defects that gymnastics maj^ decidedly aggravate. 
In these cases the mechanism of the body has become so deranged and 
disturbed that nothing short of actual readjustment can be effective. 

In the consideration of postural defects there are a few points that 
should be particularly emphasized. First, these defects may not only 
be the result of laziness or carelessness, but of more frequent occurrence 
is some previous strain or injury to the spinal column or other parts of 
the body framework. Some defect of position or symmetry of the body 
may easily follow as a result. Here gymnastic work may reduce the 
defect to a minimum, but rarely can the compensatory forces of nature 
entirely obhterate the structural disorder, unless assisted by actual, 
specific readjustment. Second, in the examination and treatment of the 
patient due attention should be given the symmetry and figure of the 
body as a whole so that relation of the part to the whole and vice versa 
may be rightly proportioned. Remember that the spinal column is 
only one part of the body outline, thus one should consider the trans- 
verse section of the body in relation to the spinal column and not the 
spinal column alone. In a word, correction of postural defects implies 
both structural rearrangement and molding of the contour. Do not 
make the mistake, for example, when correcting a deformity that involves 
the chest, of paying attention to the spine alone, but take into consid- 
eration the thorax as a whole of which the spine is only a part. 



The Practice of Osteopathy 121 



Round Shoulders 



Round Shoulders are a defective posture with which everyone is 
famihar. How many children have escaped the parents' criticism to 
sit, stand, and walk erect? And not a few of the afflicted have not suc- 
ceeded after persistently doing their best. 

Round shoulders or stoop shoulders are commonly attributed to 
indifference. Probably a few cases are due simply to laziness and in- 
difference, and others may be carelessness, and usually when they arrive 
at an age where pride of their physical demeanor and powers enters as a 
hfe factor, the child soon overcomes the postural weakness. With still 
others the correct, persistent physical training, as exemplified in mihtary 
schools, will readjust the defect. But there is a class, and by far the 
largest, where round shoulders are a very real and active weakness of the 
physical body. And the weakness is not primarily in the shoulders as 
nearly everj^one thinks. The stoop is a result. The origin is in the 
lower dorsal spinal column. Here will be found a posterior curvature 
that involves nearly the entire dorsal and lumbar areas. This is the real, 
the original cause of the larger number of round shoulders. 

This backward curve of the spinal column, instead of the forward 
curve as it should normally be at the waist, obliterates the brace or truss 
of the spinal column that is so essential in maintaining an erect posture 
of the shoulders. It allows the individual to ''fall into his stomach," 
to drop the shoulders, and as a consequence the chest cavity is depressed. 
The spine is one continuous backward bow, and when he does try to 
sit straight, and it is always with a constant effort, the normal, the phj-sio- 
logical curves of the spine are not apparent. 

First, then, there is a spinal weakness in the region of the innerva- 
tion to the digestive organs. Indigestion of various forms is a common 
accompaniment. Second, there is lessened lung and heart capacity. 
The ribs are depressed, interfering with perfect aeration and elimination 
on the part of the lungs and with normal activity and tone of the heart 
muscles. Phthisis is predisposed. Is it any wonder the child's blood 
is impoverished and anemia results from the insufficient aeration and 
poor digestion and assimilation':* Costogenic anemia may also be a re- 
sult. And, third, the shoulders are ''round" from the spinal weakness 
and flattened chest, really an effect; but while the most noticeable, it 
is the least serious. 

It is evident from careful observation and stud}'- of these cases that 
the treatment resolves itself into the treatment of a posterior spinal 



122 The Practice of Osteopathy 

curvature. Shoulder braces, steel braces and jackets, and casts have 
very Uttle place, if any, although there may be diseased bone of such 
character and severity that a cast will be necessary; this, however, would 
refer to treatment of Pott's disease and similar conditions. 

Hence, the treatment is, first to replace and readjust the mal- 
ahgned vertebrae. There must be an actual physical manipulation in 
order to correct the vertebrae at fault. This is the essential, and by far 
the primal, treatment for the key to the truss or brace that holds and 
retains the body in an erect position is then replaced. 

Second, raising the depressed ribs. Remember the depressed ribs 
are dependent upon the spinal condition. The thorax should be treated 
as a comprehensive whole, not the spinal column alone. 

Third, exercises are a valuable aid. The individual's part is as 
necessary, in a way, as the physician's, for in order to accompUsh the 
maximum there should be consistent and appreciative work on the part 
of the patient. Holding the shoulders back, the head erect and the chin 
in, drawing the abdomen in and up, all with deep breathing by the use 
of the chest muscles, the patient will be able to retain the correction ob- 
tained during treatments. "Setting up" exercises are helpful. De- 
veloping the muscles of forced expiration is excellent. Thus the patient 
must be conscious of the work required of him and act in concert with the 
physician. Minute instruction on the requirements of each case is de- 
manded. 

Good food, pure water, and fresh air are necessary, particularly 
in the anemic. Right Hving and correct environment are always in 
order. 

Painful Shoulders 

Under this heading may come a variety of conditions affecting one 
or both shoulders causing much distress and, at times, total disabiUty. 
The conditions may be the result of direct injury to the joint, systemic, 
or from spinal lesions. Anatomically the shoulder offers frequent oppor- 
tunity to injury as it has the greatest range of motion of any joint, is 
least secure in its articulation, and is most vulnerable from location. 
Once the shoulder has been dislocated it is rarely back to normal func- 
tioning again as this injury tears the capsular hgament and stretches 
the structures in relation. Many times there is only a subluxation 
in which the head of the humerus is driven upwards in the fossa, usually 
from a fall or blow on the point of the elbow. As a rule, after such an 
accident, the only thing done is to rest the joint and apply a hniment 



The Practice of Osteopath's 123 

and, after a time, begin the use of the arm. It is, however, painful and 
to save himself, the patient each time restricts movement until he reaches 
a point where he is unable to dress without assistance. It is then found 
that normal motion is reduced fully one half and even this will be ac- 
companied by pain on movement and in bed. A radiograph will, usually, 
show the condition. Articular crepitus and fibrous adhesions are 
present while the adjoining structures have undergone changes so that 
a reduction is impossible without certain preparation. Very often a 
trivial cause will disable a joint; a sudden movement which finds the 
muscles about the shoulder unprepared and the resulting lesion is so 
slight as to, often, defy detection. At first there will be swelling and 
pain but, in time, it settles down to a limited motion with more or less 
distress. 

Bursitis. — This is a condition in which the sub-deltoid bursa is 
involved or where there have been a number of bursse formed from over- 
use of the joint. One authority reports as many as twenty-five in a 
shoulder. There may be, also, tenosynovitis primarily or from exten- 
sion. These conditions may not be easily diagnosed at first. 

Brachial neuritis (chronic) beginning with or without an acute 
attack is usually from a cervical lesion involving the brachial plexus but 
most frequently it is the 5th and 6th cervicals at the origin of the cir- 
cumflex nerve. From this the deltoid is particularly affected and its 
contraction leads to pressure on the nerve and subsequent partial or 
complete paralysis. Brachial neuritis is found in an increasing number 
of osteopathic practicians and is the result of overwork of the arms and 
to strain of the upper dorsals and lower cervicals. There are contrac- 
tions of structures about the joint constantly hmiting motion and pain 
when a strain is put on them. 

Many methods for the treatment of the conditions described have 
been employed, all involving the same principle but none of them sys- 
tematized. C. H. Spencer has worked out a technique which, while 
originally intended for bursitis, has been found well adapted to all con- 
ditions described. It gives a stretching of all structures and gradually 
breaks up adhesions, both in the joint and in the tendon sheaths, so there 
is no resulting irritation which could easily result if suddenly done. His 
technique is^ : 

"First: The patient on the side, the affected shoulder up; operator 
facing the patient, places one hand on the top of the shoulder, does noth- 
ing more than fixing it; with the hand grasping the forearm above the 
1. Journal American Osteopathic Association, Jan. 1916. 



124 The Practice of Osteopathy 

wiist, push the elbow backward, the arm parallel to and ahiiost in con 
tact with the body, then pull forward in the same plane. Second: Ele- 
vate the elbow with the hands of the operator in the same position as 
before, carry the elbow in as wide a circle as possible. Third : With the 
hands still in the same position, extend the forearm with traction ; carry 
it as high in front of the patient as possible. The foregoing are designed 
to reUeve the congestion about the shoulder, bring pressure to bear on 
the subdeltoid bursa and moderate traction on the supraspinatus, infra- 
spinatus, subscapularis, teres minor and major, latissimus dorsi and the 
tendon of the biceps. These manipulations will be all that is possible 
in the more aggravated cases for some considerable period of time. As 
the tenderness subsides, the second group may be cautiously started, the 
hands in the same position as above noted, with the arm extended as 
nearly as possible at right angles with the body, carry the arm in as 
wide a circle as the pain will permit. Again, with the arm flexed at the 
elbow, one hand of the operator on the point of the shoulder and the 
forearm of the patient across the forearm of the operator, the other hand 
of the operator resting on the point of the patient's elbow, push down 
toward the middle Une of the body and carry the elbow toward the head. 
Then flex the arm and place the back of the hand behind the patient, 
flexing the shoulder in front with one hand grasping the point of the 
elbow and pull forward. This group of movements accomplishes with 
greater force the same ends obtained in the previous, and the first in 
this group is the most effective in overcoming swelling of the sub-deltoid 
bursa. Direct manipulation of the muscle masses and this bursa is 
desirable from the first." It will be noticed in all these movements that 
the joint is protected by one hand of the operator while the other is grasp- 
ing the arm of the patient. This is desirable as it makes the technique 
absolutely safe. An additional treatment will be found very effective, 
especially where the deltoid is involved. With the patient on the well 
side, facing the operator, locate the quadrilateral space which is bounded 
by the subscapularis above, the teres minor below and the long head of 
the biceps medially and the surgical neck of the humerus externally, 
and the circumflex nerve can be easily palpated along with the artery. 
[f these structures are stretched and the deltoid hfted from the shoul- 
der it will be found to free the action of both nerve and artery, one sup- 
plying the joint with nutrition and the other innervating it. 

Certain conditions for which these movements are contra-indicated 
arise and the following differential points by H. Glasscock are well to 



The Practice of Osteopathy 125 

'Rheumatism: Fever in the joint, with redness, swehing 
and other joints involved. Tuberculosis: Daily temperature and 
other tubercular foci. Neuritis: Pain in the neck and shoulder mus- 
cles, also near insertion of deltoid and in the forearm, particularly mus- 
culo spiral. Pain worse at night. No pain on movement. No swelling. 
Bursitis: No pain in neck. Pain in anterior and posterior part of 
joint and on motion. Pain near insertion of deltoid. Aim. held close 
to the body, motionless. Infection: Chill, hmited motion, severe 
pain with temperature. Dislocation. Deformity with preternatural 
mobility. Dislocation of acromlo-clavicular joint: Tenderness over 
articulation. Arm cannot be raised beyond right angle with the body, 
but elbow may be brought across the chest with external rotation of 
arm and raised perpendicular with the body without pain." The in- 
fected joint should never be manipulated and all conditions showing 
swelling, redness and pain on touch should be viewed with suspicion. 
Remember that all other conditions will almost invariably have verte- 
bral lesions, primary or secondary and a permanent result will depend 
upon their correction. 

The Prominent Hip 

A hip that is prominent and larger than its fellow is of frequent 
occurrence. It may not be necessarily conducive to a defect in posture, 
but it often is. The female is more frequently afflicted with this ana- 
tomical irregularity than the male. In the first place, the female pelvis 
is not so stable and rugged as the male pelvis, i. e., a mechanical wrench 
or fall will more easily displace the relative position of the tissues in the 
female. Then, in the second place, the dress of the woman accentuates 
irregularities of the figure, so that possibly in some instances the defect, 
from a diseased or deformed point of view, is more apparent than real. 
But of still more importance is the fact that many cases of a prominent 
hip are due to a lateral curvature of the lumbar spinal column. Lumbar 
curvatures are of common occurrence in the woman; first, the spinal col- 
umn is not so strong as in man, simply on account of the physique not 
being so robust; second, modern dress constricts the waist by the use of 
corsets and many waist bands, and the weight of heavy skirts upon the 
waist, hips and abdomen; and, third, severe strains from childbirth. 
Care should be taken that there is no 'congenital abnormalities of the lum- 
bar spine, or that congenital asymmetiy of one-half of body, or trunk or 
leg is not present. 

1. Osteopathic Physician, Nov. 1919. 



126 The Practice of Osteopathy 

Thus the principal cause of a prominent hip is the lateral lumbar 
curvature. This, through compensatory action, renders the hip on the 
concave side prominent and high, while the hip on the convex side is 
depressed and less pronounced in appearance. Dressmakers and tailors 
are all too famihar with this feature of the irregularly outlined figure, and, 
consequent!}', have to resort to ''padding" to round out the symmetry 
of the body. The mere irregularity of the figure, unfortunately, is by 
far the less serious part of the defect. Many ailments and diseases can 
be readily and directly traced to this. Not that the prominent hip 
itself necessarily always plays a leading part, but rather the lumbar 
curvature is the ca\ise of very much sufTering and misery. To enumer- 
ate the many disorders that arise from mal-aligned lumbar vertebrae 
may be unnecessary but a few will be given. A point to be emphasized 
is that the prominent hip often plays the role of a sign or symptom, 
or an effect, that an ailment or disease may be elsewhere. 

In the female one of the most common causes, if not the most com- 
mon cause by far, of disorders of menstruation, whether painful, profuse, 
or irregular, is irritation or obstruction of the lumbar spinal nerves due 
to lumbar curvatures. It is well known the lumbar spinal nerves con- 
trol, to a large extent, the pelvic organs ; consequently the osteopath pays 
particular attention to this area. Then certain intestinal disorders, 
such as appendicitis, typhoid fever, dysentery, rectal diseases, owe their 
origin to predisposing lesions here; also, bladder aihnents, and sexual 
diseases of men, and many affections of the legs, as sciatica, varicose 
veins, etc. 

In a number of instances the prominent hip will be due to a dis- 
placed innominatum. Then a lumbar curvature will result as a compen- 
satory condition. This reverses the compensatory act as heretofore 
referred to; the prominent hip, in this instance, is the cause and not the 
effect. To diagnose which is cause and which is effect will frequently 
require considerable technical knowledge and experience. The slipped 
innominatum then produces symptoms and disorders directly from its 
changed anatomical relations; the points of diagnosis are given in the 
chapter on Diagnosis. The prominent hip can easily be detected when 
the subject sits down upon an even, firm surface, or stands up, and the 
one side is compared with the other. In some cases where the prominent 
hip is due to a lumbar curvature, 'and the prominence is a secondary 
feature, the legs will be found uneven in length, but not always, for he 
lumbar curvature may straighten out when the patient lies flat upon the 
back. To diagnose the cause from effect and to differentiate the maze 



The Practice of Osteopathy 127 

of signs and symptoms that may be present is not always easy even for 
the skilled practitioner. 

The correction of a prominent hip is not ordinarily a difficult mat- 
ter. In the cases where Imnbar vertebrae are principally at fault, and 
these include the greater number, the problem is one of correcting the 
spinal curvature. Lumbar curvatures are the easiest of any of the cur- 
vatures to correct, for one is not hampered by the rib articulations, and 
the lumbar section presents an area where a leverage can readily be 
obtained. Where the innominatum is primarily at fault it is simply a 
matter of readjusting this, with probably some attention to the lumbar 
region. Care should be taken that the prominent hip is not caused by a. 
tubercular sacro-iliac disease, by hip-joint disease, by a dislocated hip, 
or by an overlapping of thigh or leg bones from fracture. 

Standing erect will, of course, be a valuable help, for standing with 
the weight on one foot will tend to make the hip on that side more promi- 
nent. But generally the reason why one favors a certain side is because 
the other side is weaker; a weak back, a slipped innominatum, or an in- 
jured leg are common causes. There are many cases where the skirts 
will have to be considerably altered after the hips have been made sym- 
metrical. 

Pendulous Abdomen 

The pendulous abdomen is another defect that is all too com- 
mon. A great many people have prominent abdomens because they do 
not stand properly, but a pendulous or prominent abdomen is not neces- 
sarily synonymous with a stout abdomen. They attempt to stand erect 
erect by drawing the shoulders back and extending the abdomen. If 
they would hold the head erect and the chin in, with the shoulders back 
and the chest forward, and draw the abdomen inward and upward, their 
figures and physiques would undergo shortly a wonderful transformation. 
These directions also apply to pregnant women. Drawing the abdo- 
men upward and inward wiU at first require considerable effort. It cer- 
tainly will not be an involuntary act for the first few days. 

The sagging of the abdomen not only causes an unsightly appear- 
ance but results in great relaxation of the abdominal muscles, interferes 
with digestive functions, displaces the pelvic organs, and weakens the 
action of the lungs and heart. 

The laxity of the abdominal muscles allows the abdominal organs — 
the intestines, stomach, kidneys, etc. — to displace downward. This 
tends to indigestion, constipation, inactivity of the liver, etc., and causes 
a score of reflex symptoms. The organs become simply weakened frou) 



128 The Practice of Osteopathy 

a lack of proper tone. This is a frequent cause of nervous prostration. 
Also it is one of the common causes of prolapsed and displaced pelvic 
organs, because the abdominal organs sag down upon them and the pelvic 
organs thus receive the brunt of the gravitative effect. Internal local 
treatment of the pelvic organs can only be a makeshift in these cases. 
The lungs and heart are weakened because the abdominal organs are 
dragging on the chest, the lungs can not aerate the blood freely owing 
to the abdominal weight and to the blood being obstructed in passing 
from the abdominal organs through the liver to the heart and lungs. 
The heart is handicapped in its work through lessened chest capacity 
and obstructed circulation. Just "suck" up the abdominal organs and 
see how much easier it is to expand the chest and to breathe. 

There are other causes for a pendulous abdomen, such as a weak- 
ened spinal nerve supply to the abdominal muscles and organs. The 
weakened nerve supply may cause a loss of tone to the abdominal organs 
themselves, so that certain organs, as the stomach and intestines, become 
dilated and prolapsed; to the ligaments, and to the tissues and organs as 
a whole so that they become gravitated. 

Through childbirth muscular fibres of the abdominal walls often 
rupture, leaving scars and a relaxed condition. Actual ruptures, hernia, 
of the abdominal muscles occur and cause a pendulous abdomen. Then 
there are cases of obesity where the pendulous abdomen is a symptom. 

Much can be done with all of these conditions through osteopathic 
work; the patient must also help himseK. The center of gravity of the 
body must be changed, and kept changed; correct posture and a constant 
effort will accomphsh considerable. The "setting up" mihtary exercises 
are excellent. Even in some cases of obesity the abdominal prominence 
can be markedly lessened by careful exercising and keeping the abdo- 
men drawn in so that the abdominal muscles, the diaphragm, and the 
chest may be strengthened. For the relaxed, flabby abdomen, self 
manipulation of the weak muscles when lying on the back will materially 
aid. 

Postural Curvatures of the Spinal Column 

Undoubtedly, the great percentage of postural defects, or slumped 
states, are dependent, directly or indirectly, upon weaknesses in the 
spinal column. As was seen, round shoulders, the prominent hip, or 
the pendulous abdomen, are often initiated by spinal deviations and de- 
formities, so naturally spinal column curvatures are a most fruitful source 
of direct defects of posture. 



The Practice op Osteopathy 129 

It is somewhat uncommon to find an anatomically true spinal col- 
umn, although this does not preclude that one's posture is defective, 
for often through pride and effort one may consciously overcome a de- 
fective posture. 

It is the purpose here to offer a few suggestions relative to the de- 
velopment of a greater symmetry of the body. Nearly every one is more 
or less interested in physical exercises and development. And especially 
to those of sedentary habits do means and methods of exercise appeal. 
' Curiously enough, in a way, nearly every layman looks upon defects in 
posture, symmetry and stature as an effect arising from lack of, or im- 
proper, exercise. He seems to be imbued with the idea that the body 
in most instances is practically permanent in construction and when ir- 
regularities in figure occur certain exercises will correct the defect. Thus 
have individuals been prone to look upon osteopathy as a method of 
passive exercises. Osteopaths should beheve most thoroughly in exer- 
cising, personal hygiene, etc., but the idea of osteopathic manipulation 
is primarily one of anatomical reconstruction, and not muscular devel- 
opment alone. The work of the osteopath is to re-adjust or to re-mold 
the body framework and the many tissues that clothe it so that normahty 
of function may predominate. The manipulation is not routinism but 
mechanical rebuilding of the tissues so that perfect freedom of vital forces 
may be forthcoming. 

The spinal column presents the most frequent as well as many ex- 
tremely interesting phases for re-correcting work. The number of ab- 
normahties as to contour to which it is subject are many and varied. 
Emphasis should be placed upon possible congenital abnormalities and 
developmental defects as sources of certain derangements. Any varia- 
tion or combination of variations with the normal or physiological curves 
constitutes an abnormaUty or pathological curve. And as a consequence 
defective posture, unless thoroughly compensated, is readily initiated. 
Not only may the normal curves be exaggerated, lessened, eliminated 
or reversed, but lateral and rotary curvatures are of frequent occurrence. 

Curvatures involving the cervical region to the extent of producing 
noticeable defects of posture are principally lateral deviations of several 
vertebrae. Wry-neck is probably the most noticeable disturbance. The 
head and neck being drawn and slightly twisted to one side is a defect 
that is both noticeable and painful. Another common source of postural 
affection is an exaggerated forward curving of the neck vertebrae. This 
produces a stooped appearance of the neck. 

The dorsal vertebrae are often curved backward too far. This 



130 The Practice of Osteopathy 

produces roundness with too decided a fullness of the upper back and 
shoulders. The chest may be somewhat flattened as a secondary effect 
but not necessarily so. Neither are the shoulders what may be termed 
"round shoulders," still such a condition may occur, for "round shoul- 
ders" are more often caused by a backward swerve of the colmnn at the 
waist line. There is often a shortning of the anterior structures whic^j 
pull the point of the shoulders forward. Forcing them backwar d w 
aid in correcting the fault. The dorsal vertebrse may be forwar 
what is termed a " straight " spine ; this results in an exaggerated "braced " 
back position. Then lateral curvatures of the dorsal spine are common, 
which in time may develop into a rotary curvature; that is, the vertebrae- 
are actuallj' rotated on their axes. Lateral curvatiu-es of the dorsal 
spine are slow and difficult to correct, for the ribs comphcate matters 
very materially. Then, also, the vertebnr are apt to be deformed. 

Curvatures of the lumbar spine, whether posterior, lateral or an- 
terior, are common. Both dorsal and lumbar curvatures, as any one 
can readily see, are extremely common sources of postm-al defects. Erect 
positions of the body are maintained through the support of the dorsal 
and lumbar vertebrae. Stooped shoulders, one shoulder lower than its 
fellow, sitting humped over, sitting on the sacrum instead of squarely 
on the buttocks, the prominent hip, standing first on one foot and then 
on the other in order to rest the back, and the many allied variations of 
incorrect postures are largely dependent on the condition of the lumbar 
and dorsal spines. 

It is not to be supposed that the above defects are the only ailments 
and disturbances that spinal curvatures cause, for, indeed, the defective 
posture may be by far a minor consideration. Disorders of body func- 
tions and affection of organic life itself are very often traced to the mal- 
aligned vertebrae. 

The causes of spinal curvatures are many, but without question 
one of the most common causes is mechanical w^renching or twisting of 
the column from falls, jars, etc. Often the strain or sprain of the sec- 
tions are readjusted through the inherent powers of the body, but there 
is a point where vis medicatrix naturae requires extraneous help to cor- 
rect the perversion; and, naturally, such aid, by virtue of the cause of 
the disturbance, should be physical force mechanically appUed. Other 
causes of spinal curvatures are contractions of muscles on one side of 
the column or paralysis of the muscles on one side; in either instance, 
muscular action is greater on one side than the other, which easily re- 
sults in a curvature. This imbalance of muscular tension, whether 



The Peactice op Osteopathy 131 

due to the above or other sources such as overfatigue or various dele- 
terious habits, is a proHfic source of lesions. And among still other 
causes may be noted, bone diseases of the spinal column, compensatory 
deformities, and constitutional weakening and irritating diseases. Also, 
some occupations predispose to certain curvatures. 

One can readily see that the treatment which is directed specifically 
to the cause of the vertebral deviation would be the most scientific. 
This is just what osteopathic work implies, direct readjustment of the 
sections at fault — not exercises, or routine stretching, or braces; although 
these latter methods may in some cases have their place as secondary 
aids. Of coiu"se exercises are usually physiological and may be em- 
ployed, in many instances, as an auxiliary. Care should be taken to 
eradicate infectious foci when present. 

Where curvatures are extreme, complicating and deforming the 
ribs, and absorbing the bodies of the vertebrae so they become wedge- 
shaped, and resulting from abscesses, no one can expect within reason to 
absolutely correct the posture. Some aggressive work can be accom- 
plished, but a perfect symmetry will not be forthcoming. It may be 
well to emphasize again that where the ribs are involved the osteopath 
is not contending with the deformity of the spinal column alone, but in 
addition the entire transverse area of the body. (See also Spinal Curva- 
tures) . 

Conclusion. — In concluding this rapid survey of a number of 
postural defects the principal lesson to be drawn is not one of developing 
the physique and thus perfecting a better posture, so much as curtailing 
and eliminating insidious beginnings of disease. These little ailments 
and deformities, of which postural defects may be the most noticeable, 
are so often the inception of more serious disorders. The anatomical 
structure being mal-adjusted, -aligned, or -positioned, easily and readily 
leads to consequences that require much time and patience to overcome. 
Poise of body represents much to every one. Poise or correct pos- 
ture coupled with careful and methodical exercise and correct breathing 
are material aids in constructive development, as well as in eliminating 
disease, for not alone may abdominal, pelvic and thoracic integrity be 
benefited, but the upper respiratory tract may be toned. 

The most important goal that osteopathic science and art is striving 
for is that of a fully developed and rounded out prophylaxis or preventive 
treatment. When the public realizes that the proverbial ounce of pre- 
vention is an established medical reality then it can truly be said our 
science has reached its ultimate good. To those who are familiar with 



132 The Practice of Osteopathy 

o^eopathic theon'-, facts, and development, it is an open secret that this 
school holds the kej^ to successful preventive treatment. The time is 
rapidly approaching when the actual lessening of diseases will be an es- 
tablished fact. Then will be the universal practice of the layman going 
periodically to his osteopath to see if there are any small or insidious be- 
ginnings of disorder or disease. 

Not only must the many deleterious habits and errors of the daily 
regimen be corrected, but after environmental, physiological and struc- 
tural adjustment, in so far as possible, has been attained, a daily regimen 
to maintain the normal should be instituted. 



The Practice of Osteopathy 133 



PROLAPSED ORGANS 



Prolapse of various organs or tissues are among the very common 
ailments that afflict all classes. Prolapse of the stomach, a kidney, the 
uterus, or the rectum is a familiar term to every one. But this condition 
may also rest with the intestines, the liver, an ovary, or even the heart. 
Outside of injuries, congenital weaknesses, and so-termed surgical 
disorders, there are commonly two constant forces predisposing to pro- 
lapsed organs, viz: gravitation and weakened innervation; the one, of 
course, is a constant factor in either health or ill health, the other is 
dependent upon acquirement. Here the latter, or acquired nervous 
weakness, will especially demand our attention. 

Where tissues are torn or lacerated, or congenital malformations are 
present, or tissues are weakened from ulceration and with a resultant 
scar tissue, or certain tumors are present, the disorder must be amenable 
largely to surgical measures if at all. 

The perpendicular position of the body favors a decided gravitation 
of the abdominal and pelvic organs. This gravitative effect being a con- 
stant one, many methods, both surgical and mechanical, have been de- 
vised to hold in approximate and relative position certain organs and 
tissues that may be prolapsed. But it is well known that outside of a 
certain few instances where surgical measures are clearly indicated the 
prevalent use of braces, bandages, supports and the like are usually poor 
makeshifts. 

The one great feature in these cases is that tonicity to organs and 
supporting muscles and tissues is more or less impaired. The tissue 
atony may vary from mere weakness to actual tearing and separating 
of the fibres. The indications in the cases about to be described are to 
stimulate a lowered nerve supply and to increase a lessened blood sup- 
ply; if this can be accomplished, supporting muscles, ligaments and other 
tissues will be able to restore the prolapsed organs to normal positions, 
thus improving functions and eliminating disease symptoms. 

In discussing the prolapse of the following organs, perhaps it should 
be noted here that all of the abdominal organs may be prolapsed as a 
whole. The intestines, stomach, liver, kidneys, etc., may actually pro- 
lapse together. This is more apt to occur in persons whose abdominal 
walls are thin and flabby. In women pregnancy is a common cause. 
When the abdominal organs have gravitated, the pelvic organs, also, are 
very likely to be disturbed and displaced; in fact, the pelvic organs are 
frequently disordered this way. 



134 The Practice of Osteopathy 

Prolapse and Dilatation of the Stomach 

Dilatation of the stomach is a much more common and serious 
affection than prolapse of the stomach, although usually the two are 
associated. Prolapse, or ptosis, of the stomach means simply a down- 
ward displacement of the organ. This is apt to take place in those cases 
where all of the abdominal organs have gravitated. There is invar- 
iably some dilatation of the organ as well. 

Weakness of the abdominal walls and of the supports of the stom- 
ach constitute the principal causes of the prolapse. Spinal deviations 
that impinge or obstruct the nerve strands (or obstruct the blood and 
lymph suppl}' to these strands) to the supporting stomach tissues is the 
most frequent cause of the ailment. General debilitating diseases, as 
anemia, cancer, etc., are indirect causes of weakened organs with con- 
sequent displacements. 

In dilatation of the stomach the condition may be either acute or 
chronic. The former is found where immense amounts of food or drink 
have been introduced. 

One of the principal causes of chronic dilatation is some obstruction 
to the opening from the stomach into the intestine, so that the stomach 
contents do not pass readily into the bowel. This leads to chronic dis- 
turbances of the stomach walls, and the food remaining in the stomach 
somewhat indefinitely weights down and stretches the walls of the stom- 
ach. The obstruction may be a tumor, or some stricture or adhesion 
from scar tissue resulting from ulceration or inflammation. The treat- 
ment of these cases comes within the province of surgical interference 
rather than other methods. 

The second important cause of chronic dilatation is muscular weak- 
ness of the walls from poor nerve supply. This is a common cause and 
osteopathy is very successful in curing these cases. The splanchnic 
nerves are below normal, usually from a slight lateral or posterior spinal 
curvature. The nerve force to the walls of the stomach not being nor- 
mal causes atony of the muscles and dilatation results. This nervo- 
muscular atony, also, results from a chronic catarrh, or from a general 
nutritional disorder as tuberculosis or anemia The treatment of the 
former would imply direct correction of nerve and blood supply with 
attention to diet; the latter can be cured only through relieving the nu- 
tritional disorder of which the stomach condition is a symptom. 

Dilatation of the stomach is most common in people of middle age 
or older. The disease is usually easily diagnosed. The symptoms may 



The Practice of Osteopathy 135 

not be indicative of the trouble beyond showing that the stomach is dis- 
turbed. Indigestion, uneasiness, and nausea are common. Vomiting 
of large quantities of material from the stomach is likely to occur. The 
patient is generally emaciated, the skin is dry, the bowels constipated, 
and the urine scanty. 

The diagnosis, as a rule, is not hard to make. Through the media 
of inspection, palpation and percussion, the careful osteopath will have 
little trouble to determine the size of the stomach. Kemp's^ distinction 
between gastroptosia and dilatation of the stomach is as follows: "In 
dilatation the lesser curvature retains its relation to the diaphragm. 
The distance between the lesser and the greater curvature is increased, 
but the lesser curvature still maintains its relation to the diaphragm, 
with the exception that the pyloric end may extend fa,rther over and 
somewhat farther down." Another instructive point relative to diag- 
nosis the above authors make is the importance of the splashing sound. 
Owing to the fact that the stomach in health closes concentrically about 
its contents and thus adapts itself to the volume of ingesta, no splash- 
ing sound can be eHcited. Three different degrees of relaxation are diag- 
nosticated as follows: "Splashing sound, which can be elicited only dur- 
ing the normal period of digestion, means simple atony; splashing sound 
produced after the legitimate time of digestion has expired means motor 
insufficiency; and splashing sound produced in the morning, after the 
night's fasting, before Hquid or food has been introduced, may mean 
stagnation, dilatation of the stomach, as imderstoo.d by most writers." 
(For a more complete outline see Dilatation of the Stomach. The ob- 
ject of this section is to present an outline of prolapsed organs as a whole, 
and to refer especially to the effectiveness of osteopathic treatment in 
this condition). 

This is a disease where osteopathy has been particularly successful 
in not only reheving distressing symptoms, but in actually curing the 
disorder. This refers to the nervo-muscular atony type, for where there 
is obstruction due to stricture or tumor of the pylorus, resulting in stom- 
ach dilatation, the treatment, from the very nature of things, must be 
largely surgical. Stomachs that have been dilated and prolapsed several 
inches have been entirely restored to function and organic integrity. 
To cure these cases is a matter of stimulating nerve control and blood 
supply to the stomach tissues, and, often of greater importance, remov- 
ing spinal impingements to the stomach nerve fibers, thus allowing na- 
ture to fully assert herself. In reality, outside of so-termed surgical 
1 . Rose and Kemp — Atonia Gastricia. 



136 The Practice of Osteopathy 

cases and other cases where the stomach dilatation is merely a symptom 
of general nutritional disorder, the primary treatment, by far, is the 
spinal one. Treatment over the stomach is a decidedly beneficial treat- 
ment; it aids materially in toning both abdominal and stomach muscles; 
still this is mostly a secondary treatment. 

Dieting is essential. Careful dieting lessens the tendency to ca- 
tarrhal inflammation and reduces the work of the stomach to a mini- 
mum. Still, nourishing food is necessary and the dieting can easily be 
carried to an extreme. Liquids should not be taken freely. Fatty and 
starchy foods should be eliminated. Give the patient food at short 
intervals. Various nutritious meats are excellent. 

In dilatation, and also general abdominal relaxation, daily abdom- 
inal treatments may be indicated. If the relaxation is pronounced, keep- 
ing the patient in bed with thorough spinal treatment two or three times 
a week, daily abdominal treatment, having the patient exercise abdom- 
inal parietes by drawing the walls in and up, upper thoracic breathing, 
and frequent feeding will accomplish comparatively quick results. The 
progress of each case depends very materially upon the general health, 
the physical status of other tissues, constitution, inheritance, environ- 
ment, age, etc. Some cases will yield in two or three months, others 
will require two or three years in order to obtain the greatest possible 
benefit. 

The Prolapsed Kidney 

A prolapsed kidney is often termed a floating kidney, or movable 
kidney, or dislocated kidney. It is of common occurrenfce, especially in 
tnin persons. Some authorities stalte that one woman out of eVery four 
has a floating kidney. It is more common in women than in men, and 
among the working class than other classes. 

The condition is usually an acquired one, following severe strains 
from lifting, falls, injuries, etc. Tt is claimed by some that a floating 
kidney arises from congenitally weakened and relaxed tissues about 
the kidney, that is, the tissues that keep the kidney normally at anchor- 
age. Thus a congenital looseness of the kidney would easily be a pre- 
disposing cause whence mechanical violence, repeated pregnancies, an 
enlarged liver, or tight lacing would act as an exciting cause. Undoubt- 
edly in some instances there is a congenital predisposition, the peritoneal 
fold attaching the kidney to the spine being loose and the capsule of fat 
retaining the kidney being scanty, but osteopathic experience has amply 
demonstrated that the tissues anchoring the kidney may in many case 



The Practice of Osteopathy 137 

become atonied and relaxed from lower dorsal spinal lesions. Rarely 
is a case presented to an osteopath that does not exhibit two apparently 
characteristic causative features, viz: spinal irregularity in the lower 
dorsal spine, and constriction of the zone about the waist, i. e., dropping 
and constricting of the floating ribs. Furthermore, correction of these 
lesions will almost invariably lessen the mobility of the palpable kidney. 

The symptoms of a floating kidney are many and variable. The 
kidney may be slightly movable or it may be so loose that one can easily 
grasp it through the walls of the abdomen. Most of the symptoms are 
of a nervous reflex nature. Indigestion, which is likely to be very per- 
sistent, flatulency, heart palpitation, painful menstruation, irritable 
bladder, etc., are the most common symptoms. Still, blueness, depression 
and morbidness are frequently present. The most distressing direct 
disturbance is the feehng of weight in the abdomen, especially on stand- 
ing, running or lifting. Sometimes the ureter becomes twisted and se- 
vere pain, colic and even collapse occurs. (Dietl's crisis.) 

The diagnosis of a dislocated kidney is not a particularly difficult 
matter. A little experience coupled with a dehcate sense of touch will 
usually readily detect abnormal mobility of the kidney. A point to 
always remember is that the kidney normally descends about one-half 
an inch with each inspiration. Care should be taken not to mistake a 
floating kidney for a movable spleen, although this is not likely, as the 
shape of the spleen is different. 

The treatment of a movable kidney under osteopathic measures 
is usually successful. In the first place a number of cases require but 
little attention, simply toning up the general health, and especially di- 
recting attention to. the abdominal walls and organs. There are a num- 
ber of cases where the kidney prolapse is incidental to general abdominal 
laxness and weakness. In more severe cases, treating the spine, raising 
the floating ribs, carefully manipulating over the abdomen, keeping 
the bowels open, and lessening liver congestion should it arise, will suf- 
fice; in fact, will remedy a good percentage of the cases. With others, a 
well fitting, medium width, elastic bandage with pad underneath will be 
beneficial. In these cases the patient should be taught how to treat the 
abdominal organs, to manipulate the abdominal walls, and to replace 
the prolapsed kidney; particularly after going to bed this can be done 
successfully by the patient and will prove a decided help in obstinate 
cases. 

Surgical measures for fixing the kidney should seldom be resorted 
to. If the patient will live a careful life, avoid unduly straining himself, 



138 The Practice of Osteopathy 

keep the bowels normal, and have the anatomical lesions corrected, he 
will come ver>' near being entirely relieved, if not absolutely. Sm-gical 
measures are not always a success. Surgeons are not operating for 
this disorder so often as in past years. (See Movable Kidney — Diseases 
of the Kidney.) 

Liver Prolapse 

Thi? is commonly termed a floating liver. There is prolapse of 
the organ as well as its being abnormally movable. It is not of frequent 
occurrence; women suffer from it much oftener than men. 

Normally, the liver is partially held in place, in the concavity of the 
diaphragm, by a number of peritoneal folds. The attachment of these 
Ugaments is to the spine and the diaphragm; their principal function 
is to prevent extended lateral movements Of greater importance in 
supporting the liver in a normal position is the integrity of the abdom- 
inal walls, and the position of the stomach and intestines. If the abdom- 
inal walls are of normal tone the liver is very apt to be in correct position. 
And the rest of the abdominal organs, especially intestines and stomach, 
act as a cushion support. Often when the liver is displaced the remain- 
ing abdominal organs are, also, out of normal position and relation to 
each other; in fact, general prolapse of the abdominal viscera is a frequent 
cause of Uver prolapse. An additional support of the liver is a certain 
cohesion of the liver and diaphragm, and the elastic traction of the lungs. 

Foremost among the causes that predispose to inelastic and atonied 
abdominal walls are spinal irregularities, deviations, and cm'vatures, 
which impinge nerve force and obstruct blood supply. These same le- 
sions weaken ligamentous supports of the liver and lessen tonicity of the 
other abdominal organs, so that local or general displacements are readily 
forthcoming. Strains, injuries, frequent pregnancies, etc., also act as 
causes that weaken the supports of abdominal tissues and organs. In a 
word it is very often the pendulous abdomen that is the immediate cause 
of a floating liver. 

It is very rare to find the liver displaced to the lower region of the 
abdomen. The ptosis is usually somewhat slight. The organ generally 
rotates on descent, the right lobe being the lowest portion, owing to the 
attachment of a ligament, the ligamentum teres, to the umbihcus. Prob- 
"Bbly in some cases there is a congenital tendency to relaxation of the 
ligaments, and, thus violent exertions and atonic and flabby abdominal 
walls and diaphragm are secondary but important factors. 

The principal symptom of a floating liver is a tumor in the right 



The Peactice of Osteopathy 139 

side, which may be low down. Palpation will usually determine this. 
Then the abdominal walls are flabby. Pain and bearing down of the 
right side are common. There is apt to be considerable indigestion. 
Various reflex symptoms are often present. The floating liver will 
seem larger than normal, as the liver is below the costal arch and much 
of it can be felt. Percussion will be of value in determining the extent 
of the disorder. 

Much can be accomplished by treatment, especially where the 
displacement is of a lesser degree. Correcting the spinal lesions, toning 
up the abdominal walls and diaphragm, and replacing the displaced or- 
gans will be extremely effectual. The abdominal bandage may be of 
service. • Certainly abdominal exercises will be beneficial. 

A point to remember is, stimulation over the abdomen beneath the 
right costal arch will cause the liver to contract and retract. This is of 
considerable osteopathic note. The liver will often recede at least a 
half an inch. This is a liver reflex (Abrams). 

Prolapsed Intestines 

Prolapse of the bowels, as a whole, or, more frequent still, of a 
part, is undoubtedly the most common form of organ prolapse. The 
intestines are so situated that they readily feel the effect of gravitative 
influences, of atonic and anemic states, and of weaknesses and disorders 
of other abdommal organs. 

Spinal irregularities come first as potent causes of bowel prolapse. 
The spinal nerves to the supports of the intestines, to the muscular coats 
of the intestines, and to the abdominal walls, are obstructed in their 
normal activity, and consequently those tissues to which these nerves 
are distributed are affected. Wasting diseases, as anemia, consump- 
tion, cancer and the like predispose to intestinal aton5^ 

The severe mechanical wrenches, strains, frequent pregnancies, 
tight lacing, heavy skirts, large abdominal tumors, obesity, cause more 
or less general or local weakness. 

The pendulous abdomen, from wrong or careless posture, and ex- 
clusive of other causes, is a common source of general bowel displace- 
ment. This form of disorder, besides being unsightly, favors abdominal 
stoutness. There are a number of instances where simply voluntarily 
holding or "sucking" the abdomen into place, until it becomes strong 
enough to support itself, has reduced one's weight by five, ten or fifteen 
pounds. These were cases where most of the adipose tissue was about 
the abdomen. Thus exercising and toning the abdominal organs by 



140 The Practice of Osteopathy 

keeping them in normal position rectified a dormant blood and lymph 
circulation, which was followed by absorption of the abdominal stout- 
ness. 

Congenital weaknesses are to be considered in many cases. The 
muscular ligaments may not be developed, the mesenteric attachments 
may be too long, and various other abnormalities may result from con- 
genital disturbances. 

Of particular local interest to the osteopth, outside of the bowels 
dislocating as a whole, are: first, the hepatic flexure; second, the ileo- 
cecal region; third, the sigmoid flexure; fourth, the rectum; and fifth, 
hernias. Each of these sections are of separate interest and will be con- 
sidered presently. 

The symptoms are extremely variable. Constipation, a feeling 
of discomfort in the bowels, nervousness, depression, lassitude and anem- 
ia are frequent. CoHcky pains in the intestines, indigestion, hysteria 
at times, are also among the symptoms. In reality a great variety 
of symptoms may be present. The patient is likely to be emaciated. 
In some cases exhaustion is marked. 

Diagnosis, as a rule, is not a difficult matter. The various neuras- 
thenic symptoms in a lean patient with constipation, indigestion, and 
stomach and intestinal distress would lead one to suspect intestinal dis- 
placement. The outline or contour of the abdomen will often reveal 
the character of the trouble. The atonic, thin and relaxed walls of the 
abdomen may readily give view of the displaced organs. Then careful 
examination by palpation and percussion will help very materially in 
the diagnosis. Radiographic examination is a decidedly helpful diag- 
nostic method. 

The liepatic flexure is frequently prolapsed. The bowel (colon) 
ascends from below upward to beneath the costal arch and then angles 
sharply into the transverse colon, which extends directly across the ab- 
domen to the left side. The ligaments that support this flexure are apt 
to become weakened or stretched and allow a descent of this section of 
the bowel, which is followed by constipation, indigestion, etc. The 
ligament especiall}' involved is the colo-hepatic ligament. The duo- 
denum may require attention. This can be raised by getting beneath 
it where the organ descends alongside of the ascending colon. The effect 
of treatment is to release tension of the duodeno-hepatic ligament which 
is closely associated with the portal vein, hepatic artery and bile-duct. 

The ileo-cecal region is an area that readily becomes congested 
and catarrhally inflamed, especially from constipation or impaction 



The Practice op Osteopathy 141 

at this point. The section often becomes atonic and prolapsed with 
resultant clogging of fecal matter. Owing to the close proximity of the 
vermiform appendix, appendicitis frequently results from the above 
condition. The osteopath can do much in these cases of appendicitis. 
Lesions are invariably found in the lumbar vertebrae or the floating 
ribs are depressed. 

The sigmoid flexure is also frequently prolapsed. The fecal 
mass often becomes impacted here, owing to a setthng or prolapse of 
this part. In some cases the prolapse is so marked that it extends to 
the rectum below and drags on the splenic flexure above. 

Lumbar and innominate lesions are the usual causes, although, it 
seems in a number of instances, that relaxed walls of the abdomen cause 
a "contraction of the diaphragm resulting in kidney displacement and 
followed by intestinal prolapse." The vertebral lesions, probably, 
first weaken the muscular coat of the bowel, then, second, the bowel sup- 
ports (other than its own inherent tonicity) and the abdominal walls. 

Prolapse of the rectum is of such separate importance that it will 
be but partly outhned here. As stated above, a source of rectal dis- 
placement arises from the section of the bowel above settling downward 
and ultimately causing invagination of one or more coats of the rectum. 
Dislocation of the coccyx is a potent cause of rectal disorders. Lumbar 
lesions, especially twists between the fourth and fifth, and fifth and 
sacrum are common causes of rectal weaknesses. Slips of the innominata 
are other causes of prolapse. 

Osteopathy has had marked success in these cases. Cures may re- 
sult from a single treatment to readjust the coccygeal displacement or 
temporarily reheve excessive physiological activity by dilating the rec- 
tal sphincter, or the treatment may demand a number of months' work 
in correcting general abdominal prolapse. Raising the sigmoid is ef- 
fectual. 

A hernia is "the protrusion of a loop or knuckle of an organ or tissue 
through an abdominal opening." Two of the common hernias of the 
intestines are inguinal and femoral. These conditions are most often 
acquired from severe straining, so that a loop of the bowel protrudes 
through a weakened and stretched area of the abdominal walls, though 
there is reason to suspect that congenital defects are often predisposing 
factors. 

Mention of the hernia is here made because, in a way, it is a form of 
bowel prolapse; that is, a limited form, and osteopathy contains certain 
possibilities for a successful treatment. Hernia has always been looked 



142 The Peactice of Osteopathy 

upon as purely a surgical disorder; i. e., remediable by surgical measures 
only. Where a truss has failed to give relief surgery has been resorted 
to. This is true in most instances, but where the hernia is in the incip- 
iency careful abdominal exercises (this should be carried out with great 
care, for severe exercise may produce a hernia or increase one already 
existing), massage to the tissues about the hernia, attention to the bow- 
els, and spinal stimulation corresponding to the weakened tissue, and 
avoidance of strains may strengthen the tissues materially about the 
hernia. 

Occasionally a loop of the intestine will prolapse into the cul-de-sac 
back of the uterus. A heavy dragging pain low down in the center of 
the abdomen and constipation or complete obstruction are the pro- 
nounced symptoms. Careful lifting of the loop of bowel by pressure 
within the vagina and traction from above with a hand outside, with 
the patient, on her back, with buttocks elevated, gives speedy relief. 

The treatment of the prolapsed bowels represents those measures 
that will replace and keep in position the displaced organs. Naturally, 
the spinal and abdominal treatment comes first; this strengthens intes- 
tinal ligaments, tones intestinal muscles, and contracts the abdominal 
parietes, and at the same time the bowels are regulated, digestion and 
nutrition improved, and the general health built up. In some cases 
abdominal supporters will be of value. In a number of instances at- 
tention to chest mobility and diaphragm tonicity will be of value. Right 
living, which is represented by proper diet, sufficient outdoor exercise 
and regular habits, is invaluable. 

The really specific treatment is to correct spinal, rib and innominate 
deviations and abnormahties. But direct local work wiU be, in many 
instances, necessary. General abdominal manipulation is good, but 
this should be supplemented by careful local treatment. The hepatic 
flexure requires a direct stimulating and replacing treatment. The 
ileo-cecal section should be raised, stimulated and emptied of the fecal 
mass. Direct upward manipulation of the sigmoid flexure in the left 
ihac fossa and of the splenic flexure beneath the left costal arch is ex- 
tremely efficacious. Care must be taken not to bruise the parts. Get- 
ting beneath the prolapsed area and gently and intelligently raising the 
bowel so that it is emptied, toned up, and vascular congestion relieved, 
are the indications. This requires careful work and the necessity of 
gentleness can not be emphasized too much. Still in all of this treat- 
ment we should never forget the absolutely essential spinal readjust- 
ment. 



The Practice of Osteopathy 143 

Rectal prolapse requires lacol internal treatment, external tissue 
correction, especially of the coccyx, an innominatum or the lumbar spine, 
and, of much importance, deep, careful and thorough work over the 
sigmoid section. 

Cases of bowel prolapse are every day experiences with the osteo- 
path. The osteopathic treatment is of great value in these and a suc- 
cessful issue is very often the result. Cases of pendulous abdomen, of 
■obstinate constipation, of chronic indigestion, of many nutritional dis- 
orders, of feehng pain, weight or dragging, locally or generally, in the 
abdomen, are very apt to be in persons suffering from prolapsed intestines. 

A number of cases of bowel prolapse are associated with general 
prolapse of abdominal organs ; that is, displacement of the stomach, kid- 
neys, liver, spleen, etc. This general condition is termed enteroptosis 
or Glenard's disease. It usually requires several months to treat it 
successfully. These patients are neurasthenic, mal-nourished, and often 
bysteriacs. The symptoms from which they suffer are innumerable. 
Mechanical weaknesses, lowered vitaUty, poor innervation and blood 
supply, and auto-intoxication are causative factors. 

The Prolapsed Uterus 

Prolapse of the uterus is of common occurrence. The prolapse 
may be incomplete or complete; the latter when the organ is presented 
to the external world. Of special interest are those affections exclusive 
of surgical cases. Ptosis of the abdominal organs upon the pelvic organs 
is a common cause of uterine prolapse. The abdominal prolapse crowds 
uterine space, congests the uterus, weakens the ligaments, and drives 
the uterus downward as a wedge. 

Lumbar spinal curvatures are frequent causes of prolapse, as well 
as other displacements of the uterus. In this region vasomotor nerves 
to the pelvic organs make their exit, and, consequently congestions, in- 
flammations, and weaknesses of supports are results. Also, slips of the 
innominata disturb the pelvic circulatory balance. Weakness of the 
uterine support from below, the vaginal walls and perineum, most often 
arises from lacerations at child-birth. Still, the vaginal walls may be- 
<3ome relaxed through other causes. Tumors and extreme congestions 
are causes of prolapse. Heavy Ufting is quite a frequent source of uterine 
displacements. Osteopathy is very successful in uterine prolapses; 
that is, any displacement of the uterus not of a surgical character. Cor- 
rection of the external causes comes first. Then local treatment to re- 
place, tone, and relieve congestion, and break up adhesions is necessary. 



144 The Practice of Osteopathy 

The external treatment is usually the primary treatment. Local work 
is not always necessary. Lacerations and other surgical indications, of 
course, require surgery. 

Ovarian Displacements 

The ovaries may be prolapsed, the left much oftener than the right. 
When prolapsed, it drops backward, downward and inward. 

Ovarian congestion, tumor, retroverted or retrofiexed uterus, tubal 
disease, and pregnancy are among the principal causes. Back of these 
congestions, tumors and uterine displacements, are the osteopathic causes, 
particularly spinal and rib lesions from the ninth dorsal downward. 
Specific lesions at the ninth and tenth dorsals and corresponding ribs, 
affecting directly ovarian tissues, and lumbar and innominate lesions 
and abdominal prolapse disturbing uterine and tubal tissues, are the 
most frequent osteopathic causes. A retroverted or retrofiexed uterus 
is often found. Uterine displacements bear down upon the ovary and 
cause its descent, and also disturb ovarian circulation. 

As has been stated, the left ovary is more apt to be displaced than 
the right. This is owing to the absence of a valve in the ovarian vein 
on the left side, and also, this vein opens at a right angle into the renal 
vein; this anatomical feature easily leads to passive congestion of the 
ovary, and thus to diseases of the organ. Then the rectum is on the 
left side and large fecal masses are apt to crowd against the ovary, which 
tends to its displacement. 

Thus it is readily seen that osteopathic treatment is very appUcable 
to ovarian displacement unless the indications are surgical. A more or 
less constant burning or sharp pain in the ovarian region, with probably 
some feeling of weight, profuse and painful menstruation, depression, 
irritability, etc., are diagnostic. However, a local examination will 
reveal the status of the ovarian position and congestion. 

The same treatment as in other organ prolapse is indicated; ton- 
ing weakened tissues, relieving congestions, replacing organ, with careful 
attention to the bowels and the general health. There are no tissue 
disorders of any part of the body wherein osteopath}^ is more thoroughly 
indicated and the results more generally satisfactory than in prolapse. 
And especially should it be remembered that in prolapse of various or- 
gans m.any vague intestinal and pelvic disorders and even ureteral and 
bladder disturbances may be traced to bowel dislocations and excessive 
kidney mol^ility in which osteopathic measures are often successful. 

Conclusion. — The purpose of this section on Prolapsed Organs 
has been to supplement the various articles on Dilatation of the Stomach, 



The Practice of Osteopaths 145 

Movable Kidney, etc., with an outline that may include relaxation of a 
part or of the whole of the abdominal viscera. The physician is all too 
prone to simply note the most offending or conspicuously disturbed or- 
gan instead of carefully analyzing all the features, great and trivial, that 
may be either apparent or marked. A general relaxation of the abdom- 
inal and pelvic organs may be found, and a nearly complete restoration 
take place under treatment, but still a lacerated perineum may have to 
be repaired before a cure is completed. Or it may be in a general ab- 
dominal ptosis that a floating kidney will resist all measures for restora- 
tion, short of surgery, and before much improvement can be obtained 
the kidney will have to be stitched into place. An enlarged liver may 
crowd the kidney out of place or a transverse colon may prolapse and 
drag on contiguous tissues and still the annoying symptoms be referred 
elsewhere. Then the primal point of general relaxation may not be in 
one organ, but there may be a simultaneous displacement of several. 

The thorax itself may be distorted from various diseases so that 
the chest is narrowed, the diaphragm displaced with consequent descension 
of the abdominal organs, and from the latter a displacement of the pelvic. 

"Far down displacement, marked changes of form, and real dis- 
figurements of the stomach are found in some cases of kyphosis and 
scolio-kyphosis. "^ The osteopath will not only find this true in some 
cases, but in many cases, although he recognizes as causative factors 
injuries to the spine causing curvatures and postural defects as prolific 
sources of abdominal relaxation. 

"Glenard's whole theory of splanchnoptosia is based on the relaxa- 
tion of the suspensory ligaments of the intestines, especially that of the 
transverse colon; and Stiller, the discoverer of the floating tenth rib, 
says that splanchnoptosia is a descent of the atonic stomach, of the 
colon (especially the transverse portion), of the kidney (the right or both 
kidneys), exceptionally of the liver or the spleen. A descent which has 
been developed mostly in tender age, in consequence of general relaxa- 
tion, especially of the peritoneal suspensory ligaments in individuals 
with congenital general dyspeptic neurasthenia, tender muscles, lean 
habit, and slender bone structure, manifested in a higher degree by a 
floating tenth rib." Stiller observed that when there is a floating tenth 
rib there is a displaced stomach and a floating kidney, although it is not 
found in every case, but never missing if the case is pronounced. The 
tenth ribs in these cases have only a ligamentous fastening and are as 
freely movable as the eleventh and twelfth. 
1. Rose and Kemp — Atonia Gastricia. 



146 The Practice of Osteopathy 

That abdominal relaxation plays a very important part in many 
diseases of the abdominal and pelvic organs, in cardiac and pulmonary 
affections, disturbs the circulation in the legs, and is the source of many 
reflex affections no one can gainsay. The osteopath should always pay 
particular attention to tonic condition of the abdominal viscera, for re- 
laxation of the suspensory tissues and walls, and atony and sluggishness 
of the organs are frequently paramount etiological factors. And the 
osteopathic treatment is the remedy par excellence. 



The Peactice of Osteopathy 147 

SKIN DISEASES 

Various skin diseases have been treated osteopathically with vary- 
ing success. So much depends upon the cause of the disturbance and 
its removal, in skin diseases, that the cure does not rest so much with 
the mere treatment, as with the necessary skill in locating the disturb- 
ing factor. One has to be continually on his guard to locate external 
irritations and disorders of the digestive and genito-urinary tracts. A 
great deal depends upon the avoidance of external influences; eating nutri- 
tious food and having an unobstructed circulation. The leading object of 
osteopathic treatment is to free the circulation and thus promote a healthy 
and unobstructed flow of blood; in no other class of diseases is this more 
essential than in skin diseases. After "the removal of cutaneous irrita- 
tions and the correction of internal disorders, the cure of the case de- 
pends upon the removal of constrictions to the cutaneous blood-vessels. 
The osteopath corrects the lesions found, relaxes the muscles thoroughly 
and stimulates the circulation to the parts involved, and promotes a 
healthy activity of all the excretory organs. When the upper part of 
the body is affected, lesions are generaUy found at the atlas and axis, 
and when the lower part of the body is affected, lesions at the fifth lum- 
bar are of common occurrence, although lesions may be located at var- 
ious points corresponding with the seat of disturbance. The constant 
use of hot baths will be found a helpful measure in many skin diseases. 
But use of soap must be considered as too much alkali will neutrahze 
the oil of the skin and cause undue dryness, but bran may be substituted 
to advantage. CleanHness is necessary but the result sought is, also, 
flushing the cutaneous vessels. There are many cases where a specific 
vertebral lesion will cause, through the peripheral nerves, a cutaneous 
irritation with intense itching and discomfort. This, in turn, produces 
an exudate with or without a crust and a condition results which is not 
amenable to any local or constitutional treatment but an adjustment 
of the lesion will in most cases bring immediate relief. Application of 
this principle will aid greatly in treatment of any skin disease. In no 
disturbance of health is it more necessary to find the cause than in skin 
disease and once found to apply specific treatment. 

Eczema is frequently met in osteopathic practice. It is the most 
common form of skin disease, comprising nearly one-third of all these 
disorders. For a differential diagnosis of the several varieties the student 
is referred to special texts. It is well to remember that the same under- 
lying causes may be basic to the various forms, for several varieties may 



148 The Practice of Osteopathy 

occur at the same time or one variety pass into another, though commonly 
one form is more prevalent. The limbs, face and genitalia are the most 
common sites, though the eruption may occur on various parts of the 
body. 

Etiology includes a number of factors, constitutional and local. 
Dietetic errors, indigestion and faulty ehmination comprise the prin- 
cipal underlying causes, often manifested through absorption of toxins 
and leucomains. In fact any disorder of the abdominal viscera, organic 
or functional, may be a predisposing factor, likewise various disorders of 
the pelvis, tuberculosis, diabetes, anemia, etc. should be considered. 
So-called gouty and rheumatic tendencies may be the constitutional basis. 

The many osteopathic lesions plaj^ a very important role in lower- 
ing not only systemic resistance but of local tissue as well. This feature 
can not be over-emphasized. 

Then local irritants, mechanical, chemical and thermal, are not to 
be neglected. These are usually of secondary importance. Micro- 
organisms are probably a complicating factor after the lowered resist- 
ance has been estabhshed. Vasomotor neurosis, through constitutional 
defects, toxins and the very significant osteopathic lesion, is probably 
an essential part of the pathogenesis. 

Treatment is usually successful if the various etiologic factors are 
eradicated. Early treatment is very important. If the disorder is 
of more than local significance change the entire daily regimen of the 
patient. Diet, out-door exercise and sufficient sleep should be definitely 
regulated. A certain amount of general treatment to improve diges- 
tion, assimilation and ehmination is imperative. An unbalanced diet 
and over eating must be corrected. In certain moist types, eliminating 
fatty foods will be helpful, while in dry forms the starches and sugars 
should be reduced. 

If there is an underlying disease this should be remedied if possible. 
Particular attention should be paid to constipation. 

Common sense in diet, rest, change of environment and free elimi- 
nation, coupled with due attention to the osteopathic lesions, will cure 
the vast majority of cases. The greatest difficulty arises where there 
is some underlying disease. The parts should be protected against irri- 
tation such as dirt, cold, soap, and too much water. Meddlesome local 
treatment is to be guarded against. A simple application is boric acid, 
rice-flour or corn-starch, or where there is much itching add carbolic 
acid to the saturated solution of boric acid. Substitute bran for soap 
for cleansing purposes. 



The Practice of Osteopathy 149 

Herpes Simplex, fever-blister, or ''cold sore" comprise two prin- 
cipal varieties: herpes facialis and herpes genitalis. The first occurs 
upon or near the lips, face, neck or ears. When the herpes is on the 
tongue or the mucous membrane within the mouth it is commonly termed 
" canker sores. " 

Herpes genitalis is located on the prepuce, glans penis or farther 
back upon the penis. In the female the labia majora and minora and 
vestibule are the usual locations. Lack of cleanhness, sexual excitement 
and adherent prepuce are causative factors, though predisposing factors 
such as faulty circulation and disturbed innervation are to be consid- 
ered. 

In "cold sores" there is often some gastro-intestinal disturbance, 
especially intestinal stasis, cold in the head and other infections that 
supply toxins which irritate the nerves. No doubt there are under- 
lying osteopathic lesions that lower the local nerve resistance or block 
the impulses such as vertebral and inferior maxillary lesions. The pre- 
disposing disturbance is probably due to the Gasserian ganghon. 

Cold winds and excessive exposure to the sun's rays will effect the 
tissues over the mental and infraorbital foramina, tensing the muscles 
and irritating the nerves at these points. On palpation they will be 
found sensitive. Frequent rotary motion by tip cf finger over foramina 
will open them and allow congestion to drain. 

Herpes Zoster, or shingles, is an acute inflammatory disease char- 
acterized by groups of small vesicles, usually along the course of the inter- 
costal nerves on one side of the body. Before the vesicles appear there 
is more or less severe neuralgia. The eruption is unilateral, very rarely 
bilateral. The nearby lymphatics are usually enlarged. 

Though the intercostal nerves are the ones most frequently involved, 
still the lumbar, thigh, trifacial and other cutaneous nerves may be 
affected. 

The most common lesion is an inflammation of the posterior spinal 
ganglion which usually involves the fibers of the entire nerve. Inflamma- 
tion of the nerve outside of the ganghon will cause the disorder. Toxins 
from various infectious sources are often exciting causes. Vertebral 
and rib lesions are always found; and where the Gasserian ganghon is 
involved lesions of the inferior maxilla and upper cervical vertebriB 
are predisposing factors. Thus osteopathic lesions from traumatism, 
cold and wet, and imbalance of muscular tension are important. Ex- 
udates, tumors, pleuritic and pulmonary affections are to be consid- 
ered as possible sources. 



150 The Practice of Osteopathy 

Treatment. — Adjust vertebral lesions and carefully raise and 
separate ribs if intercostals are affected. Look after vertebral origin 
of any other nerve or nerves if otherwise. Local application of talcum 
or starch or boric acid will generally be sufficient. 

Urticaria, hives or nettle rash is a common affection often due to 
some derangement of the digestive tract. This may be a mechanical 
irritation or of a toxic nature. Every one is familiar with the various 
foods that are apt to cause the hives, shell fish, strawberries, cheese, 
pork, oatmeal, mushrooms, etc. 

The irritation may be a reflex one from the visceral disturbance; 
also, there may be irritation of the pelvic organs that would give rise to 
the trouble. It is well known that certain drugs will produce urticarial 
eruptions. There are cases where the irritation is simply local due to 
the nettle, mosquito bites and wasp stings. 

In chronic cases intestinal stasis, nervous exhaustion and nephritic 
diseases are important. 

No doubt osteopathic lesions frequently determine the location of 
the wheals. These lesions affect the innervation and thus estabfish a 
basis for the reflex vasomotor effect. This is in the nature of spasm of 
the cutaneous vessels quickly followed by dilatation with exudation of 
serum. The irritant probably acts on the walls of the blood vessels. 

Treatment consists of thoroughly emptying the bowels by warm 
water enema, correcting the diet, toning the viscera and adjusting the 
osteopathic lesions. Thorough attention to the patient's environment, 
daily habits and occupation are of value. Warm soda baths will relieve 
the itching. 

Acne is a common skin disorder that is characterized by an inflam- 
mation of the sebaceous glands of the nature of papules, tubercles or 
pustules. The face, shoulders, chest and back are the regions usually 
involved. It generally, appears about puberty. Blackheads is the 
starting point; these are accompanied with greasy sldn and dust, and 
influenced by micro-organisms and more or less intestinal disorder. 

The general or systemic health no doubt affects the local disorder, 
as in many skin diseases; for various intestinal derangements as indi- 
gestion, constipation, etc.; pelvic and menstrual irregularities; general 
ill health; anemia, etc. affect circulatory, glandular and nervous integ- 
rity. Any disturbance of normal elimination is important. 

The treatment consists of careful attention to the general health 
and to the local innervation of the face or region involved. Measures 
that tone the bodily organs such as outdoor fife, regular habits, plenty of 
sleep and correct diet are important. In some cases the X-ray is of value. 



The Practice of Osteopathy 151 

ANIMAL PARASITES 

Tape Worms 

Varieties. — Taenia solium; taenia saginata; bothriocephalus latus. 

The larvae of tape worms are introduced into the intestinal canal 
by food and drink. The parasite reaches adult growth in the intestines. 
The larval forms are then found again in the muscles and solid organs. 

Taenia Solium. — This is derived from the hog, and is the most 
common form in this country. When mature it is from two to four 
yards in length. The head is small, about the size of a pin, and pro- 
vided with four cup-hke suckers surrounded by a double row of hook- 
lets, hence it is called the armed tape-worm. The head is fastened to 
the body by a thread-Hke neck, and following the neck, the body occurs 
in segments. The sexual organs, both male and female, occur in the 
center of the broad surface of the segment. The segments are about 
one milUmeter in length and seven or eight miUimeters in breadth. There 
are thousands of ova in each mature segment. The worm attams its 
growth in about twelve to fifteen weeks, after which time the segments 
are shed and passed. For further development the ova must gain en- 
trance to the stomach of a pig or of man, and passing from the stom- 
ach they may reach the muscles and organs and develop into larvae or 
cysticerci. 

Taenia Saginata. — This is derived from beef, and is much longer 
and larger than the taenia solium. It is from five to six yards in length; 
the head is over two millimeters in breadth, is square shaped, and has 
four large sucking discs, without booklets; hence it is called the unarmed 
tape-worm, in contradistinction to the hooked variety. The segments 
are thicker and the ova larger, and they are passed and ingested in the 
same manner as the taenia soHum. 

Bothriocephalus Latus.— This is found especially in Europe and 
is very long, measuring from eight to ten yards; it is derived from fish, 
is not provided with booklets, but has two lateral grooves. The segments 
are short and wide, the sexual organs being on the narrow side of the 
segment. 

Etiology. — Unhealthy condition of the stomach and intestines is 
the predisposing, and uncleanhness an important, factor in the occur- 
rence of tape-worm. Those eating imperfectly cooked beef, pork, fish 
or other meats, and those handling fresh meats, are liable to be affected 
with tape-worm. 



152 The Practice of Osteopathy 

When the ovum is taken into the stomach the capsule is dissolved 
and the embryo passes into the small intestines, fastening itself into the 
mucous membrane, by its booklets and suckers and grooves. 

Symptoms.— Tape-worms occur in the human being at all ageS- 
Oftentimes s^-mptoms are absent, the expulsion of segments being noticed 
and thus the worms accidentally discovered. The tape-worm is seldom 
dangerous, but if a worm is known to exist it is always a source of con- 
siderable anxiety on the part of the patient. Severe anemia may re- 
sult and be wrongly diagnosed. 

There are dyspeptic symptoms, coUcky pains, nausea and occasion- 
ally diarrhea. The appetite is variable, sometimes ravenous. This 
condition is followed by loss of flesh and various reflex phenomena, as 
vertigo, headache, convulsions, palpitation, choreic movements, itching 
of the nose and anus, paralysis, and rarely, insanity. In addition to 
these symptoms there may be a wrinkled countenance, sensation of a 
cold stream winding itself toward the back immediately after a meal, 
pain in various parts of the body and ringing in the ears. The decisive 
diagnostic symptom is to find segments of the worm in the stools. 

Diagnosis. — Discovery of the ova or segments in the passages of 
the bowels is the only proof of the presence of a tape- worm. 

Prognosis. — Favorable in all cases. 

Treatment. — Prophylactic treatment is necessary. Meats should 
be thoroughly cooked so that the larvae will be destroyed; and all seg- 
ments of tape-worms passed in the stools should be burned — by no means 
should they be thrown outside or in the water-closet. 

The immediate expulsion of a tape-worm is not a necessity. First 
of all the mode of living, and then the general state of health should be 
corrected. Tape-worms invariably result from a general state of un- 
healthiness, and with improved health and corrected digestive processes 
the worms cannot exist, and in a short time will be expelled. Expulsion 
of the head is necessary before the case will be cured, for if the head is 
not expelled new segments will continue to grow. 

Stimulating the liver to increase the amount of bile, and increasing 
the activity of the digestive glands of the stomach and intestines, by a 
thorough treatment of the splanchnic region and direct treatment over 
the abdomen, will usually be sufficient for the cure of intestinal para- 
sites. The treatment will probably have to be repeated several times, 
in order that the intestines may regain a healthy tone, so that the para- 
site will not find favorable conditions for its existence within the intes- 



The Practice of Osteopathy 153 

tmes, and that the bile may be secreted in sufficient quantities to dis- 
lodge the worm. 

Hahnemann claimed, "that during a period of comparative health 
tape-worms do not inhabit the intestines proper, but rather the remnants 
of food and fecal matter contained in the intestines, living quietly as in a 
world of their own without the least inconvenience to the patient and 
finding their sustenance in the contents of the bowels. During this 
state they do not come in contact with intestinal walls, and remain 
harmless. But when from any cause a person is attacked by an acute 
disease the contents of the bowels become offensive to the parasite, which 
in its writhing and distress touches and irritates the sensitive intestinal 
lining, thus increasing the complaints of the patient considerably by a 
peculiar kind of cramp-like colic. (In similar manner the human foetus 
in the womb becomes restless, twists its body and moves whenever the 
mother is sick, but floats quietly in the hquor amnii, without distressing . 
Tier while she is well.) " This but harmonizes with the osteopathic 
theory and practice with regard to tape-worm, that there is an unhealthy 
condition of the intestines which predisposes to the affection, and con- 
sequently the cure must be a correction of such a disordered state. 

During the treatment, if a light diet of milk and broths is given, it 
will favor an earher removal of the parasite, by helping to remove the 
mucus in which the head is embedded. If this fails extract of male fern 
is suggested. 

Ascaris Lumbricoides (Round Worm) 

This is the most common parasite, and is found principally in chil- 
dren; it is also found in cattle and hogs. It is of a yellowish brown 
color and in form resembles earth worms. The worm is cyhndrical, 
pointed at both ends; the female is from seven to twelve inches in length, 
and the male from four to eight inches. They are probably introduced 
into the stomach by food and drink. They occupy the upper part of 
the small intestine, and are usually one or two in number, though they 
may be numerous. Occasionally they migrate into the stomach and are 
ejected by vomiting, or into the trachea and produce suffocation, or into 
the larynx or Eustachian tube, or they may pass downward to the anus, 
or into the l)ilc ducts. 

Symptoms. — Oftentimes symptoms are absent. There may be 
dyspepsia, colicky pains, mucous stools, meteorism, vertigo, fretful- 
ness, voracious appetite, anemia, sallow complexion, headache, chorea 
and convulsions. Other symptoms may be present, as grinding of the 



154 The Practice of Osteopathy 

teeth and itching of the nose and anus. Obstruction of the bowels has 
occurred. If a worm enters the bile duct obstructive jaundice occurs. 
A decisive diagnosis can be given only when the worm is seen. 

Treatment. — Particular attention should be paid the liver, for it 
is here that we must seek the natural remedy in the form of bile, in order 
to eject and cleanse the system from nematodes. 

Modes of improper living should be corrected ; cleanUness is essential, 
and there should be attention to the general health of the patient. Thor- 
ough correction of all defects of the spinal column in the region of the 
splanchnics, and careful direct treatment of the bowels is indicated. The 
child may be put to bed and fasted twenty-four hours, then the liver 
strongly stimulated to increase flow of bile. 

If the above treatment is not successful oil of wormwood may be 
employed. 

Oxyuris Vermicularls 

(Thread-worm ; Pin- worm) 

This small parasite, commonly seen in children, is from three to 
five millimeters long in the male and about twenty millimeters in the 
female, is blunt at one end and sharp at the other, and occupies the colon 
and rectum. They are probably introduced into the intestines in the 
ova, by uncooked fruits and vegetables, or by the dirty hands of mothers 
and nurses of the infants. They vary greatly in number; migrate to 
the rectum where they deposit their eggs, and are often discharged in 
the feces, where they appear like pieces of ordinary white thread. 

Symptoms. — Loss of appetite, anemia, restlessness and irritability 
are marked. The itching becomes intolerable when the worms come 
down in the rectum to the anus and within the folds about the anal 
orifice. In the female the worms maj^ wander into the vagina where 
they become particularly distressing, and thus may produce excessive 
sexual excitement and cause nymphomania and masturbation. 

Treatment. — Cleanhness of the most scrupulous kind should be 
demanded in every instance. Injections of cold salt water (repeated 
for at least ten days) and other agents within the rectum will destroy 
the eggs as soon as they are deposited, besides reheving the terrible 
itching. In obstinate cases use quassia decoction. 

Attention to the general health of the patient and great care of the 
intestines and other digestive organs are absolutely necessary. The 
spinal treatment to the intestines and other digestive organs, as well as 
thorough direct treatment over the abdomen, is indicated. 



The Practice of Osteopathy 155 



Uncinariasis 



European hook-worm disease ; Miner's anemia; Ankylostomiasis; Hook- 
worm disease) 

This disease results from infection by the hook-worm of any of the 
various types. In Europe it is found in Italy, Belgium, Germany, 
France and Switzerland. In America it seems to be of Africo-Asiatic 
origin but was first discovered in the Southern states and abounds chiefly 
in Texas, Florida, Georgia, North and South Carolina as well as in the 
West Indies. Infection comes from unprotected feces that are allowed 
to be spread where the feet or hands may come in contact as it is 
without doubt that the contagion occurs through the skin. One au- 
thority states that hook-worm is rarely found except in cases where 
ground itch has occurred within a period of eight years. Negroes har- 
bor the parasite and transmit it but seem immune to its effects while the 
poorer whites are afflicted to a large degree. The worms are carried from 
some abrasion of the skin, by the blood to the heart and lungs, thence 
to the pharynx and swallowed, thence to the duodenum and jejunum 
where they attach themselves to the lining walls. Here they not only 
feed upon the blood but develop a toxin. The female worm is about 
twice the size of the male, 10 to 18 mm. as against 6 to 11 mm. and 
there is slight difference between the old and new world varieties. 
The head is provided with four hook shaped teeth which form the 
attachment to the intestine arid it is very secure. 

Diagnosis. — For years the languid, dull, expressionless, lack-luster 
of eye and general unambitious characteristics of the inhabitants of the 
great sand belt of the United States attracted attention and was at- 
tributed to laziness but the discovery of the hook-worm explained the 
cause. Children are stunted in mind and body and have a muddy, dirty 
white complexion. 

At the beginning there must be a very considerable colony of the 
parasites to cause symptoms but as the disease advances there is a dis- 
tention of the abdomen from enlargement of the spleen and liver and 
from flatulency. There is palpitation, shortness of breath, cardiac 
bruits from the severe anemia while edema of the feet and legs is rather 
common. The blood shows a severe secondary anemia with its coagu- 
lation time much increased. Leucocytosis is not common; hemoglobin 
is from one-tenth to one-half normal with erythrocytes about half nor- 
mal. 

Treatment. — The removal of the worms with the least possible 



156 The Practice of Osteopathy 

harm to the body is indicated. Thymol is a poison which is not ab- 
sorbed by the body, when carefully given, and which is very toxic to 
the parasite. The dose varies from eight grains for a child under five 
years of age, to forty-five for an adult. Thymol is soluble in fats and in 
alcohol, so that for a day or so before the thymol is given, and from one 
to four days after, no fats or alcohol should be taken. The best way 
to avoid poisoning by thymol is to give the patient charcoal, then no 
fats or alcohol is permitted until the treatment is completed. When 
the stools become black, the thjanol is given on an empty stomach. A 
purgative is given a few hours later. Enemas should be used very freely 
in order to faciUtate the removal of the injured or poisoned worms. An- 
other dose of charcoal is given, and when the stools are black again, the 
patient ma}^ return to his ordinary diet. The denial of fats to. the per- 
son so thoroughly accustomed to bacon three times a day is a factor met 
with difficulty in dealing with patients of the ordinary class with the 
disease. (CHnical Osteopathy.) 

Prophylaxis. — After treatment it is imperative to prevent re- 
infection and to do that the most rigorous sanitary measures must be 
instituted. All feces must be disposed of and habits of cleanliness in 
defecation insisted upon while negroes, who harbor the worm without 
showing symptoms, must be looked after as well as the actual victims. 
Care of the feet is important and shoes should be worn in infected regions 
and all abrasions of the skin protected. Drinking water must be un- 
contaminated which presents a problem as wells and springs are usually 
unprotected. Absolute and persistent cleanhness is the answer to the 
question of prevention. 

Trichiniasis 

Trichiniasis is a name given to a disease produced by the embryos 
of the trichina spiralis. In the adult condition the trichina spiraUs 
lives in the small intestines. The embryos migrate into the muscles 
where they finally become encapsulated. Man is infected by eating 
insufficiently cooked pork containing the encapsulated worm, which is 
set free during the digestive process. About the third day they attain 
their full growth and become sexually mature. Each one discharges 
large numbers of embryos. As soon as born the young brood is carried 
away from the bowel and invade the muscles through various channels^ 
principally by means of the blood stream and along the connective-tissue 
routes. The female trichina may bring forth several broods of embryos 
in succession. In nine or ten days after infection the fiist brood reaches 



The Practice of Osteopathy 157 

its destination. They attain to maturity in about two weeks after enter- 
ing the muscular tissue. In this process an interstitial myositis is ex- 
cited and a fibrous capsule is formed in four to six weeks. The capsule 
gradually becomes thicker and finally calcareous infiltration may take 
place. 

Thorough cooking destroys the parasite. The disease is most fre- 
quent among the Germans who eat raw ham and sausages. 

Symptoms. — These are sometimes absent, especially when only a 
few are eaten. If large numbers have been ingested, gastro-intestinal 
symptoms develop in the course of a few days. Vomiting, diarrhea, and 
pain in the abdomen may be present. 

In from one to two weeks muscular symptoms develop. There is 
fever, muscular pain, especially during motion, and the muscles are stiff, 
tense and sometimes swollen. When the respiratory muscles are involved 
dyspnea is produced, which may prove fatal. Eosinophilia is a helpful 
diagnostic point. Edema, especially of the face, is an important symp- 
tom. Profuse sweats, itching and tingling of the skin have been ob- 
served. 

Diagnosis. — Epidemics of this disease are more easily diagnosed 
than an isolated case. Among the Germans, if cases of apparent typhoid 
fever occur after a picnic or other feasting occasion, where raw ham or 
sausages have been indulged in, this disease should be suspected. Ex- 
amination of the stools and of the muscles will be of aid. The worms 
may be discovered in the pork, a portion of which has been eaten by the 
patient. 

Prognosis. — This depends upon the number of worms ingested. 
The prognosis should always be guarded. Early, marked diarrhea is 
favorable. 

Treatment. — Prophylactic treatment is of great importance in 
trichiniasis. Inspection of the meat supply, is doing much to prevent 
trichiniasis; although the most practical way to prevent the disease is 
to thoroughly cook all pork and sausages. The central portions of the 
meat should be well cooked. 

In the feeding of hogs care should be taken that they do not receive 
any offal, but only milk, grain, vegetables, etc. 

When a person is infected with trichiniasis, thorough and prompt 
evacuation of the bowels should be performed at once, so that the em- 
bryos will not have time to pass into the muscles, but will be ejected 
from the body. This should be followed by a thorough and persistent 
treatment for several days of the liver and intestines; treat both the 



158 The Practice of Osteopathy 

liver and intestines directly and through the spine. The object of this 
treatment is to render all the digestive juices active, so that they may dis- 
lodge the animal parasite, and to prevent their passing into the muscles. 
Also keep the bowels active for several days. 

When the larval parasites have entered the muscles, a treatment 
cannot be apphed to affect them directly, but the health of the body 
should be maintained if possible, and the severer symptoms, as the mus- 
cular pains, weakness and insomnia combated. Thorough manipula- 
tion, massage and hot baths will be of special aid in relieving the stiff- 
ness and weakness of the muscles. 

Filaria 

(Filaria Sanguinis-Hominis) 

There are two varieties. One is a thread-hke worm with tapering, 
blunt ends, appearing in the blood at night, hence called nocturna, 
while the other is of shghtly different form, appearing in the blood only 
by day and is called diurna. 

The mosquito is the communicating host of the parasite. During 
the night, or should the patient sleep during the day, the nocturna 
appears in the peripheral circulation, while during the other interval they 
are probably in the other vessels, particularly the lungs. 

After the mosquito has taken blood from an affected patient it re- 
quires from six to seven days for the metamorphosis of the minute filaria 
which are then lodged in the probosis of the mosquito and introduced 
into the blood of the next victim. The adult parasite is from three to 
four inches long and the thickness of a coarse hair, with clear sexual 
distinction. 

Pathologically there are no distinct lesions, as the parent worm 
must establish one. Lymphatic engorgement may result from plugging of 
the thoracic duct or of a large lymphatic with consequent engorgement 
which may develop s5anptoms in the inguinal glands, pelvic and lumbar 
lymphatic trunks. As these varicosities develop rupture may occur; 
if into the genito-urinary tract chyluria or chylocele may result, or if in 
the abdominal cavity chylous ascites. 

Lymphangitis follows a lymph stasis, which later results in ele- 
phantiasis. (Barbadoes leg.) 

Symptoms. — Elephantiasis affects the legs, but the arms rarely; 
the labia of the female and scrotum of the male; occasionally the breasts 
and other parts of the body. Fever is present on account of the lym- 
phangitis, accompanied by rigors and delirium and there is marked local 



The Practice of Osteopathy 159 

inflammation. The attack terminates in a pronounced sweat. In 
deeper parts there is deep seated pain and signs of sepsis, while abscesses 
may develop over the inflamed area. 

The varicose inguinal glands are doughy, soft and painless, with 
both sides affected aUke. The scrotum is affected by the extension, and 
at times the testes. 

Treatment is surgical, as the tumors must be removed. Unless 
the female worm is also removed this is, however, only palliative. 

Methylene blue is said to be destructive to the filaria and it is prac- 
tically harmless to the human body. The only treatment is one that 
will aid in building up the general health. 



160 The Practice of Osteopathy 

HEMORRHAGES 

IVasal Hemorrhage 

(Nose bleed ; Epistaxis) 

Osteopathic Etiology and Pathology. — Traumatism, such as 
picking the nose, blows, and surgical operations; straining when coughing; 
nasal tumors and ulcerations; lesions of the atlas, or any lesion of the 
upper cervical vertebrae, that would interfere with the vasomotor dis- 
tribution to the nose and cause local congestion or weakness of the blood 
vessels ; obstructions to the general circulation ; irregularities or suppres- 
sion of the menstrual flow may result in nose bleed, as a vicarious men- 
struation; suppression of a habitual hemorrhoidal discharge. 

Pathologically the great frequency of nasal hemorrhage is due 
to the great vascularity of the nasal mucous membrane. Usually in 
cases of spontaneous origin, bleeding is from the region of the septal 
artery. Spontaneous bleeding may also occur from posterior hyper- 
trophies or adenoid vegetations. The blood flowing downward into 
the fauces, is expectorated in such cases, and may be mistaken for a 
hemorrhage from the lungs. 

Treatment. — The position of the individual is important. He 
should assume a sitting posture, or as nearly so as possible. Holding the 
nostrils tightly, or plugging them with a piece of cotton, will favor the 
formation and retention of a clot, so that the hemorrhage may be con- 
trolled. Pressure upon the carotid artery, or upon the facial artery at 
the angle of the inferior maxilla, will slow the blood current and favor 
the formation of a clot, also pressure on the sides of the bridge of the 
nose may influence it. Correcting any lesions that may exist in the 
superior cervical region, as derangement of the vertebrae or contracted 
muscles, wiH remove obstructions or irritations to the vasomotor system 
of the affected region, and thus equaUze the vascular system. Holding 
the arms above the head, and the application of ice to the nose are of aid 
in some cases. Also, injection of cold or hot water into the nostrils. 
In serious and obstinate cases, where other methods fail, a plugging of 
the anterior and posterior nares should be resorted to, using absorbent 
cotton or gauze. 

Broncho-pulmonary Hemorrhage 

(Hemoptysis) 
Osteopathic Etiology and Pathology. — Pulmonary congestion; 
croupous pneumonia; tuberculosis; hemorrhagic infarction; ulcers of 



The Practice of Osteopathy 161 

the larynx, trachea or bronchi; gangrene of the lung; fibrinous bronchitis, 
carcinoma of the lung; lesions of the ribs or vertebrae from the second to 
the seventh dorsal inclusive, may cause diseases of the bronchial tubes 
or lungs, that result in hemoptysis, or the hemorrhage may be caused 
directly by extreme congestion resulting from the disordered vasomotor 
nerves; diseases of the heart, such as mitral disease, causing pulmonary 
congestion; aneurism of the branches of the pulmonary artery; vicarious 
menstruation from deranged menstrual functions; diseases of the vessel 
walls, or blood, as scurvy, anemia, hemophilia, etc. 

Pathologically in many cases, the lesions are microscopic, con- 
sisting of ruptured capillaries. In other cases larger vessels may be 
ruptured, or are the seat of erosion. Many other lesions may be ob- 
served. After death the bronchial mucosa is occasionally found inflamed 
and the lung tissues paler than normal. 

Diagnosis. — A differential diagnosis must be made between epis- 
taxis, hemoptysis and hematemesis. 

In epistaxis the blood may flow from the posterior nares into the 
pharynx; it causes coughing and a discharge of the blood may occur the 
same as in hemoptysis. A careful examination of the nasal region alone 
can determine the source of the bleeding. 

In hemoptysis the history of the case as to pulmonary or cardiac 
diseases is to be considered. There is a feeling of weight and of un- 
easiness in the chest. A salty taste and a tickling of the throat precedes 
the bleeding. The blood is ejected by coughing and is bright red, frothy, 
very Httle coagula, and is alkaline in reaction. 

In hematemesis the history would indicate disease of the stom- 
ach, spleen, liver or heart. Uneasiness, and occasionally nausea and 
faintness, precedes the bleeding. The blood is ejected by vomiting, and 
is dark, clotted or fluid, mixed with food, and is of acid reaction. In a 
few instances the blood due to hemoptysis may be swallowed, and vom- 
ited. 

Treatment. — In all these cases of hemoptysis the patient should be 
placed in bed and absolute rest demanded. An attempt should at once 
be made to correct any lesion that may be found influencing the cause 
of the bleeding. Correcting lesions to the vasomotor nerves of the lungs 
and bronchial tubes, and equahzing the disturbed vascular area, may be 
sufficient in a number of cases. These lesions will be found principally 
in the upper dorsal region. In some cases, perhaps, there is an impair- 
ment of the trophic nerves by the same lesions, thus interfering with the 



162 The Practice of Osteopathy 

tone of the vessel-walls and pulmonary tissues. The diet should be light, 
nutritious and non-stimulating. The use of hot drinks is to be avoided. 
The rapidity of the heart's action should be reduced. This is best per- 
formed by thorough treatment of the dorsal spinal nerves of the left side 
over the heart, and by inhibition in the sub-occipital region. The ice- 
bag to the precordia is also helpful. Iced drinks and the eating of ice is 
of aid. Stimulation of the systemic circulation will be of value in help- 
ing to relieve the pulmonary congestion, although the two systems are 
somewhat independent of each other. Also, hot foot baths and the 
evacuation of the bowels may be of additional value. In cases due to or- 
ganic disease of the heart, the mind and body should receive absolute 
rest, so that the diseased areas may be strengthened as much as possible; 
besides a tonic treatment for the heart's action is necessary. 

After the hemorrhage has subsided care should be taken that bleed- 
ing does not occur again. All irritations of the respiratory tract should 
be avoided. A stimulating diet, tobacco and alcohol should be avoided. 
Nutritious food and a moderate amount of exercise is indicated. 

Hemorrhage of the Stomach 

(Hematemesis) 

Osteopathic Etiology. — Injuries to the stomach; local diseases, as 
congestion, ulcers and cancer; vicarious menstruation; a mechanical 
obstruction to the portal circulation; spinal lesions to the vasomotor 
nerves of the stomach; alterations in the blood; perforation of the stom- 
ach walls, involving a blood vessel; disease of some neighboring organ. 

Diagnosis. — A careful examination of the case and of the blood 
ejected will be necessary to determine the nature of the cause. The 
differential diagnosis as to the source of the blood, whether from the 
stomach or lungs, was given under hemoptysis. 

Treatment. — Correction of any lesions that may influence the 
blood pressure in the region of the stomach, is the first requisite. Treat- 
ment of the splanchnics has the greatest influence upon the vasomotor 
nerves to the stomach. Treatment of the vagi nerves and of the fourth 
and fifth dorsals, will quiet the violent movem nts of the stomach, and 
thus aid in controlling the hemorrhage. Stimulation of the cervical 
sympathetics and heat applied to the feet will tend to equalize the vas- 
cular system, and thus lessen the gastric congestion. The application 
of a broad flat ice-bag over the stomach will be of great value. Keep 
the patient quiet in bed. Surgical interference may be necessary. 



The Practice of Osteopathy 163 



Intestinal Hemorrhage 

Osteopathic Etiology. — An obstructed circulation of the blood 
through the venaporta, as in diseases of the heart, lungs and liver; le- 
sions of the vertebree deranging spinal nerves to the intestinal blood sup- 
ply; injuries caused by corroding or cutting substances; mechanical in- 
juries to the intestines; degeneration or erosions of the blood-vessels 
from ulcers of the intestines, as from typhoid fever, typhus, dysentery, 
etc. ; disordered menstrual or hemorrhoidal discharges. 

Diagnosis. — The locality of the intestines affected can be approxi- 
mately determined by an examination of the discharged blood. When 
the blood comes from the upper part of the intestines, it is generally 
dark and mixed with the intestinal contents, which gives it a tarry ap- 
pearance. It is generally red and fluid when it comes from the lower 
portion of the bowels. If from the stomach, the blood is thoroughly 
mixed with fecal matter. Throwing the passage into water, the water is 
colored red when it contains blood, and if the contents contain bile 
the water is colored green or yellow. Also, noting the areas of contracted 
muscles, as in intestinal colic, will aid in the regional diagnosis. 

Treatment. — Absolute rest in all cases is necessary, the patient 
remaining as quiet as possible. Food, in severe cases, should not be 
given for ten or twelve hours. The bed-pan should be used in caring for 
the evacuations. Correction of the lesions along the spinal region, 
chiefly of the lower dorsal and lumbar regions, that are impeding the 
innervation to the intestines, should be attended to at once. This treat- 
ment tends to reUeve any hyperemic condition of the intestinal mucosa 
and influences the whole vasomotor area of the mesentery. Direct 
treatment of the abdomen in a few cases is of great value to reheve ob- 
structed and contracted vessels in the mesentery, but in certain patho- 
logical conditions, e. g., typhoid fever, leave the abdomen alone. Treat- 
ment (inhibition) along the spinal column from the sixth dorsal to the 
coccyx is helpful in all cases to quiet the peristalsis of the intestines. In 
severe cases cold drinks, eating of ice and an ice pack to the abdomen are 
of aid. In a few instances surgical measures will be necessary. 

Hematuria 

Osteopathic Etiology. — Congestion and acute inflammation of 

the kidneys, exacerbations of pyeUtis, renal calcuh, chronic nephritis, 

traumatism, tuberculosis, etc.; affections of the urinary tract, as calculi 

or lacerations of the ureter; calculi, cystitis, ulcerations, etc., of the blad- 



164 The Practice of Osteopathy 

der; calculi, gonorrhoea, parasites, etc., of the urethra ; general diseases, 
chiefly the acute specific fevers and blood diseases; blows, wounds and 
traumatic influences, external to the kidneys; lesions of the renal splanch- 
nics. 

Diagnosis of the locality of the hemorrhage in the urinary tract: 
In hemorrhage from the kidney the blood is thoroughly mixed with the 
urine, giving a uniform color. Blood casts and leucocytes are present. 
In hemorrhage from the ureters the blood is usually molded in clots 
which conform to the shape of the ureter. The clots appear like small 
dark worms. In hemorrhage from the bladder the blood is not thor- 
oughly mixed with the urine and large clots form upon standing. In 
hemorrhage from the urethra the blood often discharges without mic- 
turition. When urine is passed the blood precedes the passage of urine. 

Treatment.— Rest is essential. A correction of the lesions to the 
renal splanchnics is necessary to control the congestion and inflamma- 
tion of the kidneys. When the ureters, bladder or urethra is involved, 
attention must be given to the condition of the spinal column below the 
renal splanchnics. In all cases the inhibitory treatment to the lower 
spinal column and ice to the loins are of value. If surgery is indicated, 
do not delay operation. 

Uterine Hemorrliage 

Most of the causes of uterine hemorrhage come under the subject 
of obstetrics; others under menorrhagia and metrorrhagia. Such will 
be found in obstetrical and gynecological works. 

Treatment. — The patient should assume the dorsal position with 
the buttocks raised. If any displacement of the uterus is present or 
if there is any foreign material in the uterus, usually such should be cor- 
rected or removed at once. Stimulation of the clitoris is a most effectual 
means to control uterine hemorrhage; it contracts the circular fibres of 
the uterus. Stimulation of the uterus directly through the vagina, and 
over the abdomen, and stimulation of the upper wall of the vagina, will 
aid in contracting the uterus. A quick, unexpected pull of the hair on 
the mons veneris wiU have the effect of closing the capillaries by shock 
to the nervous control (Dr. Still). Before closing the os, however, it is 
w^ell to know that there is no irritating foreign material within the body 
of the uterus. Correction of obstructions of the vasomotor nerves of the 
uterus through the splanchnic and lumbar region is important. Com- 
pression of the abdominal aorta, and vaginal injections of hot water 
may be of aid, as will also a hot water bag at the lumbar region and ice 



The Practice of Osteopathy 165 

water bag over symphysis. In severe cases inversion of the body, if it 
can be done with safety, may be performed. Packing the vagina is a 
method resorted to occasionally in severe cases. 

Hiccoughs 

Occasionally there is a case of hiccoughs that has been continuous 
for hours or even days and that all efforts have failed to stop. They are 
caused by an irritation to the peripheral distribution of the phrenic 
nerve from some gastric disturbance or a local irritant acting upon the 
center in the medulla. It may follow fright or great emotion and be 
associated in persistant form in rheumatism, typhoid fever and other 
febrile diseases. It follows abdominal operations at times and is very 
distressing. When occurring in elderly people with pneumonia and in 
peritonitis with distention it usually marks the end. The same may be 
said in case of carcinoma of the stomach and bowels. 

Treatment. — Go first to the origin of the phrenic nerve at the 
third, fourth and fifth cervical and, if there is a lesion as there will prob- 
ably be, adjust it and note results. This will be sufficient in many cases. 
Faihng, bring direct pressure on the nerve just above the clavicle and 
anterior to the sterno-mastoid muscle and release the scaleni muscles. 
After this examine and treat at the fifth and twelfth dorsals. Cor- 
rect any lesions but best results will be had from inhibition at these points. 
Another method is to stand beside the patient and insert the fingers of 
both hands under the costal end of the ribs and lightly pull. Firm pressure 
over the solar plexus with flat of the hand is sometimes beneficial. In 
hysterical cases, drawing out the tongue will often be effective and it has 
been suggested that standing the patient on the head will stop them in 
short order. Tickling the nose to produce violent sneezing is an ancient 
remedy. Some one of these will cure the case, as osteopathy has never 
failed so far as recorded. 

The stomach should be emptied of all irritating matter to prevent 
recurrence. 



166 The Practice of Osteopathy 

VARICOSE VEINS 

In varicose veins there is a dilatation of the calibre of the veins and 
their valves are insufficient. The walls are irregularly thinned, length- 
ened and tortuous. 

Osteopathic Etiology and Patliology. — The internal saphen- 
ous is the vein most frequently affected, although any vein throughout 
the body may become varicose. Commonly, varicose veins occur in 
the lower extremities and occasionally in the arms. 

The valvular insufbciency is caused by stretching of the wall of 
the vein, thus separating the thin, free edges and leaving an interspace 
that allows regurgitation of the blood. The valves becoming insuffi- 
cient, the column of blood in the veins has no support against gravity, 
and being interrupted in its course does not flow normally into collateral 
channels. The walls of the veins become thin, as does also the adjacent 
skin, thus increasing the danger of a rupture, either external or sub- 
cutaneous. 

Varicose veins are most frequently found in females, following uterine 
enlargements. The condition may be due to any obstruction or con- 
striction that prevents the free return of blood from the veins, such as 
dislocations of the hip, either slight or complete, dislocations of innomi- 
nata, contractions of adductor magnus muscle affecting femoral vein, 
prolapse of diaphragm obstructmg vena cava, tissue constrictions 
about the saphenous opening, garters, and, in fact, anything that might 
impede the free venous flow. The tendency to varicose veins increases 
as age advances, and many cases are found among people of middle life 
who have been accustomed to standing a great deal. Injuries to the 
pelvis, thigh or leg, lessening the nutrition to the leg, or injuries to the 
nerves, as vertebral dislocations in the lower dorsal or lumbar regions 
(the fourth lumbar especially) may be causes of varicose veins. Preg- 
nancy or tumors in the abdomen or pelvis, causing pressure upon the 
iliac veins, are occasionally causes. Distention of the sigmoid flexure, 
causing pressure upon the left iliac vein, or distention of the cecum; press- 
ing upon the right iliac vein, are fruitful sources, as are also diseases of 
the heart and lungs. Varicose veins of the upper extremities are due to 
occupations requiring overuse of the arms. 

Complications. — Varicocele, hemorrhoids, labial varix in the 
female, varix over pubes, ulceration and eczema due to disturbances of 
nutrition, edema and thrombus. 

Symptoms. — Lower Extremities. — Cramping pains in the hmbs 



The Practice op Osteopathy 167 

■upon rising. Fullness and heaviness of the limbs. Inspection may 
reveal superficial varicose veins near the saphenous opening, upon the 
external thigh, in the popHteal space, upon the external leg or behind 
the ankles. Edema and congestion of the foot and ankles occur in a 
few cases. Pain is quite a prominent symptom, due to pressure upon 
the nerve fibres. Eczema and itching are due to disturbed innervation 
and blood supply to the skin. Ulceration may occur, due to the burst- 
ing of a vein. 

Upper Extremities. — Before the varicosity appears there is usually 
pain or a feehng as of a sprain in the involved region of the arm. The 
pain is usually confined to a muscle or group of muscles. 

Treatment. — The majority of cases are due to disorders about the 
pelvis, hip or thigh, and the treatment resolves itself into the removal 
of these obstructions or constrictions. Occasionally cases are caused by 
partial dislocations of the hip joint, which can be easily overlooked during 
a hurried examination. The sHpping of an innominatum is an important 
factor. Rest in a recumbent position, attention to the general health, 
and especial attention to the bowels and hver, are essential in acute 
attacks. Occasionally the heart and lungs are at fault. Treatment 
twice per week should consist of removing any of the numerous causes 
of the condition, and spinal treatment as well; then the leg should re- 
ceive special attention. Remember, thrombi may form and the 
vein must, under no circumstances, be touched in the treatment. Be- 
gin by carefully rotating the leg to stretch contracted tissue about the 
saphenous opening, then separate the tendons of the popHteal space and 
follow the course of the vein to the abdomen and relax tissue about it. 
Keep patient off the feet as much as possible and elevate the leg when 
sitting. 

In rupture of varicose veins the hemorrhage can be arrested by ele- 
vating the Hmb and applying pressure with the fingers, above and below 
the wound, until a compress and bandage can be applied. The support 
of the varicose veins by elastic stockings will ease the pain and prevent 
edema in many cases, but, as a rule, it is a direct hindrance to the circu- 
lation on account of the necessity of having the stocking fit closely. Sur- 
gical operations are rarely indicated. 

Phlebitis 

(Phlegmasia alba dolcns; milk leg) 
An inflammation of a vein. In the condition described here it is 
a puerperal septic inflammation of the femoral vein. About the third 



168 The Practice of Osteopathy 

week after confinement there is a swelling of the leg with or without 
redness. Great pain accompanies the condition and the temperature 
gradually rises to 102°-3°. As understood by osteopaths, this is the re- 
sult of a partial closing of the saphenous opening during parturition so 
that the venous flow is partly stopped. 

Treatment consists in carefully rotating the leg at the hip so that 
the fascia lata is spread, opening the lumen of the vein so the conges- 
tion will drain out. There will, also, probably be found innominate or 
lumbar lesions which must be adjusted with the result that almost im- 
mediate relief is given as a rule. 

Chronic Phlebitis 

The chronic form shows considerable inflammation along the line 
of the vein marked by tenderness, edema and thickening of tissue. The 
entire leg may be more or less involved through circulatory injury. In 
these cases will be found definite innominte lesions of a primary type 
or the distortion is superinduced by lumbar lesions. A few cases are 
quickly cleared up through adjustment that is readily secured. How- 
ever, in others, there being considerable thickening of the sacro-iliac 
articulating tissues, some time may be required to get complete ad- 
justment and consequent restoration of femoral circulation. In addi- 
tion to this, careful abduction, flexion, hyperextension and circum- 
duction is indicated. This last technique should be executed with great 
care and with due regard to pathology. If Dr. Still's emphatic com- 
mand were followed, that all maternity patients should have both legs 
rotated and innominates inspected, there would be no phlebitis cases, 
acute or chronic. 



The Practice of Osteopathy 169 



THE RECTUM 

To treat the rectum intelligently and thoroughly, requires special 
knowledge on the part of the osteopath. A speculum should be used in 
many cases when making an examination, and all abnormal conditions 
carefully inspected with the eye; although much can usually be noted 
by the examination with the finger alone. The best position in which 
to give an examination and treatment is to have the patient on the side, 
with thighs flexed upon the abdomen. In a few cases the patient may 
lean over an operating table. 

The objects of rectal treatment are many — to reheve hemorrhoids, 
etc., of the mucouS membrane; to correct a dislocated coccyx; to treat an 
enlarged prostate gland; to replace a prolapsed rectum; to tone the lower 
bowel in cases of constipation; to give reflex stimuU to the heart and 
lungs, in cases of fainting, paroxysms, etc.; to relieve severe pains in the 
rectum at the time of the menstrual period, and to relieve congestion, 
inflammation, contracted tissues, etc., of local sources; to relax spasms 
in croup, and to remove tension to the nervous sj^stem in some forms of 
insomnia. In fact, so many diseases are affected by reflex irritations 
from the rectum that its examination is a necessity in many cases. The 
phrase "when in doubt treat the rectum" was coined by a progressive 
student and there is an element of truth in it. Surgical assistance to 
treatment will be considered under hemorrhoids. 

The principal need of osteopathic internal rectal treatment, is: 
(1) To relax all contracted and constricted fibres about the waUs of the 
rectum and between the sacrum and coccyx. (2) To correct a dislocated 
coccyx. (3) To dilate the sphincters thoroughly, in order to reheve irri- 
tations about the sphincters, and to stimulate the sympathetic nerves. 

Work through the rectum to treat an enlarged prostate gland, to 
correct a displaced uterus, and to make a more thorough examination 
of the uterine tissues, the Fallopian tubes and the ovaries, is a frequent 
occurrence. 

In giving local treatment, cleanse the fingers and oil the index 
finger; then, after introducing it into the rectum relax the contracted 
tissues by an upward sweeping motion on all sides. This treatment re- 
Heves all obstructions to vessels and nerves caused by contracted fibres, 
and tones the rectal walls. In prolapsed sigmoid, causing obstructive 
constipation, the finger can be used to separate the folds of mucous mem- 
brane and open the lumen of the bowel. Frequently there will be enough 



170 The Practice of Osteopathy 

tone to the muscular coat so that the irritation will set up slight peris- 
talsis and cause the bowel to draw up to a considerable degree. In chil- 
dren where there is much straining at the stool, the sigmoid will often 
be found down and by using the httle finger the same results can be ac- 
compUshed and much rehef given. 

To dilate and stretch the sphincters thoroughly a speculum or 
dilator should be used under anesthesia; still, considerable can be done 
by one or two fingers. The sphincter should be thoroughly stretched in 
all directions, care being taken when an instrument is used that too much 
force is not appHed. Secure as much voluntary relaxation of the sphinc- 
ter as possible. Inhibition at 2d and 3d sacral will aid. This treat- 
ment is of aid in cases of hemorrhoids and prolapse of the rectum, in con- 
stipation due to the loss of tonicity of the lower bowels, in tightness of 
the sphincters, in pain of the rectum, and in stimulating the heart and 
lungs. In cases of a prolapsed rectum, due to irritation about the sphinc- 
ters, causing tenesmus, this treatment is of special value, as it gives the 
sphincter a phj^siological rest. Frequency of treatment per rectum must 
depend entirely on the patient and disease. It can be given daily in 
many cases and is frequently so indicated in acute hemorrhoids, pros- 
tatic troubles, etc. 

According to Quain, the sensory nerves to the rectum are from the 
second, third and fourth sacrals. Some of the motor fibres of the cir- 
cular muscles of the rectum are from the lower dorsal and upper two lum- 
bar nerves; these pass by the aortic plexus to the inferior mesenteric 
ganglion. Associated with these fibres, are the inhibitory fibres of the 
longitudinal muscles of the rectum. The sacral nerves contain motor 
fibres to the longitudinal muscles, and inhibitor}^ fibres to the circular 
muscles of the rectum. In all cases of rectal trouble, the lower dorsal 
and upper lumbar vertebrae may be found deranged, and thus interfere 
with the rectal nerves. Relaxation of the sacral muscles over the sacral 
foramina has a marked effect in reUeving tenesmus. In dysentery, 
where there is a constant desire to defecate, a thorough upward relaxation 
of the sacral muscles will give great relief. 

Proctitis or inflammation of the rectum is not an uncommon dis- 
order. The disease has been divided into acute, chronic, gonorrheal, 
dysenteric, and diphtheritic. Foreign bodies, impacted feces, cold, 
purgatives, prolapse of the sigmoid, and lumbar, coccygeal and innom- 
inate lesions are the most important causative factors. The acute 
form is more frequently found in older people. The symptoms are 
tenesmus, frequent evacuations of blood and mucus (possibly pus). 



The Peactice OF Osteopathy 171 

prolapse of the mucous membrane, feeling of fullness, and radiating pains. 
The gonorrheal, diphtheritic and dysenteric forms are of rare occurrence, 
with the exception that the dysenteric may be somewhat frequent. The 
treatment is to remove all local irritations, cleanse the bowels, and put 
the patient in bed. AU irritating foods are to be prohibited. Use milk, 
soups, beef-juice, soft boiled eggs and similar foods. Correct all osteo- 
pathic lesions; especially will inhibition over the sacral foramina relieve 
the tenesmus. Cold water in the rectum and appUed to the anus will 
be beneficial. If abscesses occur, employ surgical measures. 

Prolapse of the rectum is another common rectal disorder. Acute 
cases are especially found in children, due to straining at stool. The 
sacrum is more straight, and thus violent straining, coughing, etc., the 
more readily produces prolapse. Prolapse of the mucous membrane 
is the most common, although all of the rectal coats may be involved. 
Prolapse of the upper part of the rectum into the lower or invagination 
is frequently met with by osteopaths. The sigmoid may prolapse and 
also affect the rectum. The treatment is to return the mass, using 
an anesthetic if necessary. If it is not retained, place straps across the 
buttocks. Then with attention to lesions that may be disturbing and 
weakening the rectal walls, and thorough local toning treatment, the 
prognosis should be favorable. In high rectal prolapse local attention 
is necessary as well as deep treatment through the abdominal walls to 
the sigmoid and upper rectum. The use of Cole's irrigator for high 
enema will replace and elevate both the upper rectum and sigmoid and 
greatly aid in a cure. Regularity of habits and proper food are essentials. 

Hemorrhoids • 

Definition. — A dilated or varicose condition of the plexus of veins 
lying in the sub-mucous tissue of the lower part of the rectum. The di- 
latation of these hemorrhoidal veins may extend into the adjoining sub- 
cutaneous tissues and mucous membrane, and the perirectal plexus and 
adjoining venous plexuses of the bladder, uterus, vagina and sacral canal 
may become involved. 

Osteopathic Etiology and Pathology. — The chief predisposing 
cause of piles is man's erect position and the absence of valves in the 
hemorrhoidal veins. Thus a retardation or stagnation of the portal 
vein would cause a backward movement of the entire cokram. It is 
evident that such a downward pressure of the blood in the portal system 
would dilate and extend the blood vessels, to the very capillaries in the 
rectal region. 



172 The Practice of Osteopathy 

This retardation may arise from several causes: obstruction of 
the portal vein, from diseases of the liver; diseases of the heart; obstruc- 
tion or destruction of the capillaries of the lungs; pressure from a gravid 
uterus, tumor, etc. ; a general loss of tonicity of the abdominal walls, as 
in persons who take but little exercise ; the excessive use of wine, tea and 
coffee; injuries to the spinal column, especially in the lumbar, sacral and 
coccygeal regions; a dislocation of an innominate bone; lifting; consti- 
pation; straining at stool; carelessness of the calls of nature, etc. Ca- 
tarrh of the bowels may cause a congestion of the mucous membrane and 
consequently piles. Hereditary influence may be a factor in a few cases. 
Hemorrhoids are divided into two classes, external and internal. 
An external pile is one that arises from the margin of the anus outside 
of the external sphincter muscle. It differs from the internal pile from 
the fact that it is always composed either of skin or hypertropliied con- 
nective tissue, forming a mere cutaneous tag, or else it is composed of a 
small cutaneous vein enlarged by a clot of blood. The internal hemor- 
rhoids are composed mostly of enlarged veins and are connected by hy- 
pertrophied connective tissue. They have a free arterial supply and are 
covered by the mucous membrane of the rectum. They are due, usually, 
to an affection of the middle hemorrhoidal blood supply, thereby being 
a part of the visceral vascular system. Internal hemorrhoids, when pro- 
truding, can be returned within the rectum, while the external ones can- 
not. The venous turgescence varies in size from a pea to a walnut. 
They may be single or may surround the entire anal opening like a bunch 
of grapes. 

Repeated attacks of engorgement of the veins involved, will in time 
change the mucous membrane or the sub-mucous tissue, and cause ca- 
tarrhal swelling of the mucous membrane, or hyperplasia of the connec- 
tive tissue. At first the hemorrhoid is usually a blood tumor, but in 
chronic cases it is oftentimes made up largely of connective tissue. Ow- 
ing to pressure of the varicose veins, atrophy of the mucous and sub- 
mucous tissue may occur. The white or sKmy hemorrhoids occur when 
these roughened parts of the mucous membrane become inflamed and 
thickened, resulting in suppuration. 

Symptoms. — The symptoms are quite diagnostic and need not 
be mistaken. Besides the appearance of tumors, there may be consti- 
pation, pain during stools, indigestion, headache and pain in the back. 
Hemorrhages frequently occur, and if suddenly checked, as by cold^ 
other disturbances may occur, as congestion of the head, lungs, stom- 
ach, liver, kidneys, etc., which may result in hemorrhages from these or- 



The Practice of Osteopathy 173 

gans. Fissures of the anus, contraction of the rectal sphincters and pro- 
lapse of the rectum may occur. Occasionally in old people there is a 
varicose state of the veins of the neck of the bladder, and in females, 
of the uterus and vagina, which causes hemorrhages of these organs. 
The communicating plexus of the spinal canal may be affected, causing 
weight, numbness and pain, so as to simulate a lesion of the cord. The 
patient may have a hypochondriacal disposition and be disinclined to 
work, especially at mental labor. 

Prognosis. — Depends upon the predisposing and immediate causes, 
but a large majority of cases can be cured. 

Treatment.— A thorough examination of the patient should be 
made, not only to ascertain the extent of the local trouble, but to under- 
stand thoroughly the general health of the sufferer, especiallj'- the state 
of the heart, lungs and liver. 

Many cases of hemorrhoids are caused by lesions in the lumbar 
and sacral regions, and especially dislocations of the coccyx (usually 
anterior) and the innominata. Correcting these lesions will oftentimes 
cure the hemorrhoidal disorder. Simple dilatation of the rectum once a 
week, in addition to other treatment, is of great aid in curing hemorrhoids, 
not a few of the cases being cured by dilatation alone. It relaxes the tis- 
sues about the tumefied vessels. Treatment is rarely necessary above 
the second lumbar, (unless there is more or less of a constitutional dis- 
order) as the superior hemorrhoidal blood-vessel of the inferior mesenteric 
is given off about opposite the second lumbar. 

In cases where the abdominal walls have become relaxed, a treat- 
ment should be given to strengthen the abdominal muscles and viscera. 
Particular attention should be given the liver. Treatment should be 
given over the abdominal muscles directly, and also to the spinal nerves 
of the same region. The diet should be strictly regulated and the bowels 
kept loose, and stimulants, indigestible food, full meals and too much 
meat should be avoided. Injection of cold water before stools is a good 
prophylactic, and appHcations of cold water to the protruding pile will 
be of some help in reheving the congestion. A squatting position dur- 
ing defecation will reheve considerable strain. 

Hemorrhoids in the acute state, within twelve or twenty-four 
hours from the engorgement, yield quickly to treatment. The local 
technique is to relax the tissues about the tumor, especially above and 
along the line of the vein, then with pressure at its base carefully force 
out the engorged blood. Follow this up by another treatment the next 
day and continue until normal. The vein wall, not being permanently 



174 The Practice of Osteopathy 

stretched, will contract and if the irritating cause is found, there is little 
danger of return. Remember, in a case like this, the danger of embolism 
and be sure a clot has not formed. Cases of hemorrhage at stool, dur- 
ing or immediately following evacuation, when not from a bleeding pile, 
may be of considerable quantity and the source difficult to locate. It 
may be due to ulcerations or easily ruptured capillaries of the mucosa, 
but the cause will in many cases be found in the innominata and a re- 
duction of the lesion give rehef. 

Rectal conditions, associated with piles, and requiring surgery 
after treatment has failed, are: iiemorrhoids, which are of such long 
standing as to become organized tissue, (these will keep up continual ir- 
ritation and cannot be absorbed); saccules or pocket', formed by folds 
of mucous membrane catching and holding particles of feces, gradually 
enlarging and ending with considerable reflex symptoms ; fistulae, com- 
plete or incomplete, may frequently be healed by adjusting coccygeal 
or innominate lesions, but are apt to recur from the tract not being clean 
in the center or bottom; abscesses in or about the anus or rectum are 
usually traced to coccygeal, innominate, or local interference to circu- 
lation; fissure, complete dilatation under anesthesia to insure physio- 
logical rest of parts, is probably the best treatment. It is suggested 
that a fissure may be healed by making surgically clean, touching with 
iodine and coating with collodium. Papillae are small, hard black- 
capped papules in the lower rectum, each one involving a nerve terminal 
and causing much distress. All these conditions give rise to much dis- 
comfort and with surgical assistance can be cured without much trouble. 
It is not necessary to make them a major operation and do uncalled-for 
things. The less surgery about the rectal sphincter the better. 

Care of the anus and rectum after operation or successful treat- 
ment is a factor in preventing return. First, there should be soluble, 
non-irritating stools, which do not tend to bring about prolapse from 
straining. Diet and regularity contribute to this. Second, absolute 
cleanliness. This can only be obtained by following the stool with an 
enema of four or five ounces of cool water and immediately passing it. 
It will bring forth a considerable quantity of feces which would other- 
wise have been retained for another twenty-four hours. This procedure 
following, as it does, the stool does not in any way interfere with the 
normal function or create a habit. The anus should then be thoroughly 
washed in cool water and as thoroughly dried. Dusting with borated 
talcum powder, starch, etc., will prevent chafing. 



The Practice of Osteopathy 175 

GENITO-URINARY 

The Prostate Gland 

This gland is subject to several painful and annoying diseases, con- 
trolling, as it does, the flow of urine and exerting such a profound influence 
over the sexual functions. The nerves to the prostate pass between the 
gland and the levator ani muscle, and the secretory branches are from the 
sacral nerves, while Quain gives the sensory as from the tenth, eleventh 
(twelfth) dorsal, first, second and third sacral and fifth lumbar. Lesions 
affecting the prostate are occasionally found at the tenth and eleventh 
dorsal and fifth lumbar, while the innominate lesions are common causes 
of trouble. These should be corrected, if present, and local treatment 
given to the gland. ''Massage of the prostate," says Lydston,^ "prop- 
erly performed, is one of the most valuable advances in genito-urinary 
therapeutics that has been developed in many years." Osteopathic 
technique is to place the patient on the side, knees flexed, and standing 
in front insert the index finger. Care must be used not to bruise the 
gland and it must be touched Hghtly when sensitive. Relax tissue about 
the gland, and, then, from the median fine with an outward movement, 
massage the surface of each lobe. This infiuences the blood and nerve 
supply, while the pressure will tend to reheve congestion. Length of 
treatment, as well as frequency, depends entirely upon conditions. Do 
not make the mistake of treating the perineum instead of the gland and 
do not gouge it with the finger. Remember it is sensitive tissue. 

Hypertrophy is most commonly met with in practice, as twenty per 
cent, of men past middle life are said to be afflicted. It is probablj'" not a 
sequence of old age, but due to chronic, congestive and inflammatory 
conditions. Anything which would produce these conditions— spinal 
lesions, excessive venery, masturbation, or other more innocent causes — 
would in time bring about enlargement. As the length of catheter 
life is estimated at six years it is of great importance that the condition 
be early recognized, for in advanced stages surgery is the last resort. 
In early stages the prognosis is good, either for a cure or to stop further 
enlargement, while many enlarged ones at the catheter stage have been 
greatly benefited or cured. Treatment of the gland once per week is 
usually enough, but in older cases can be given semi-weekly. Look 
well to nerve and blood supply. 

Acute Prostatitis is a serious and painful inflammation, causing 
1. Twcntiolh Century Practice of Medicine, Vol. XXI. 



176 The Practice of Osteopathy 

urinary retention usually. It results from trauma, horseback riding, 
over exertion, gonorrhea and its mal-treatment, etc. Lower dorsal and 
lumbar lesions are frequent. This condition must be closely watched. 
Inhibition of the sacral nerves will help control pain and stop any spasm 
of the sphincter. Cold apphcations to the gland externally at the peri- 
neum will aid in reducing inflammation. Local treatment should at first 
be given to the adjacent tissues as the gland will be very sensitive. Later 
direct massage will be of great benefit. 

Chronic Prostatitis may follow an acute attack or it may originate 
as a chronic or sub-acute affection. Frequent micturition and dull pain, 
referred to the perinemn and rectum, with the local examination, make 
diagnosis sure. The spinal lesions should be corrected and the gland 
massaged. This will induce absorption, by squeezing out the inflam- 
matory products and do much toward preventing future hypertrophy. 
"Massage is done by the finger. The patient is placed in the knee- 
elbow position and massage employed for four minutes daily. The value 
of massage in chronic prostatitis is very great, but should be employed 
with much caution and never in cases of suppuration."^ 

Prostatorrliea is often taken for spermatorrhea and any irritation 
of anterior sacral nerves would cause undue activity to the secretory 
nerves to the gland. This is easily determined. 

Tlie Seminal Vesicles can be reached just above the prostate, 
and if inflamed and tender or if engorged by inspissated seminal fluid, 
local treatment will be of benefit. Frequent massage, daily in some cases, 
to the gland and treatment to the sympathetic nerves above the trigone 
of the bladder, to the nerve fibres passing along the spermatic cord, 
and to the arteries directly, will be of the greatest aid in impotency. 

In Clironic Gonorrliea, where the gonococcus has found lodgement 
in and about the gland, it can be more readily dislodged by massage than 
by an}^ other form of treatment. 

Retention ol urine from nervous excitement or other minor causes, 
can often be overcome by local massage of the prostate. 

Spastic stricture can usually be cured by work about the prostate 
and its innervation . 

Varicocele 

A varicose enlargement'of the veins of the spermatic cord, epididymis 
and testicle. In varicocelefthe pampiniform plexus is usually enlarged, 
but all the veins of the cordfmaj^be involved. The swelhng gets smaller 
1. C. Kriiger, Munch Med. Woch. 



The Practice of Osteopathy 177 

under compression or in a horizontal position and enlarges again on stand- 
ing erect. It is almost invariably found on the left side, and the testicle 
on the affected side is generally smaller and softer than its fellow. 

The predisposing causes are a longer and tortuous spermatic vein 
on the left side; the absence of support of the veins from surrounding 
muscles; the imperfect valves; the entry of the left spermatic vein into 
the renal vein at a right angle, instead of at an acute angle hke the right 
vein; the more liabihty of compression of the left spermatic vein by ac- 
cumulation of feces in the sigmoid flexure; the lack of normal exercise of 
the sexual functions in young, immarried adults. Lesions in lower dor- 
sal and upper lumbar affect the condition; the eleventh dorsal particu- 
larly. A lesion at the second lumbar may cause neuralgia of the testicle 
with engorgement of the vein. 

The exciting causes are straining during stool, heavy lifting, ex- 
cessive sexual indulgence or anything that would determine more blood 
to the testicles. Varicocele is similar to the varicose state of the hemor- 
rhoidal veins and maj^ have Uke causes. 

The diagnosis is easily made. The feeUng of the veins between 
the fingers hke a convolution of earth worms; dull, aching, dragging 
sensation, and possibly prostration, weakness and dejectedness of spir- 
its, are characteristic symptom.s. "The condition is devoid of danger, 
except that it often begets morbid fears on the part' of the patient, us- 
ually the result of suggestion."^ 

The treatment consists of regulation of the bowels, removal of 
such predisposing and exciting causes as may be found, treatment of 
the vessels along the spermatic cord, and treatment to the lower dorsal 
and lumbar regions. In severe cases a suspensary bandage will give 
temporary relief. Surgical interference may be necessary in some cases 
in order to effect a cure. 

Impotency 

Results from treatment in these conditions are particularly grati- 
fying and offer a great field of activity in this day of sensational medical 
advertising. This condition can well be classed under four heads. Ex- 
haustive, Traumatic, Psychic and Organic. 

Exhaustive Impotency is the result of functional abuse, mastur- 
bation in early life, excessive venery, coupled with intemperate use of 
alcohol and improper diet without sufficient sleep. It can be symp- 
tomatic in neurasthenia. There is at first irritation of the spinal centers, 
1. Deaver's Surgical Anatomy, Vol. II, p. 652. 



178 The Practice of Osteopathy 

which causes exaggerated sexual activity, and later this is followed by 
complete or partial loss of function. The first step is for a radical reform 
in habits; regulation of the bowels, as they will likely be constipated; 
direction of the mind into wholesome channels, and then skillfully di- 
rected spinal treatment. Where there has been masturbation, look well 
for sources of irritation to the parts ; a long foreskin or adherent prepuce 
indicates surgical aid, or there may be a lesion at the sacrals involving the 
nervi erigentes or, of greater importance, the pudic nerve. The in- 
nominatum can be at fault in this. The lower dorsal, ribs and upper lum- 
bar are of importance. Kraft-Ebing says: "Conditions of absolute 
impotency are, however, rare, and are caused only by severe vertebral 
and nervous diseases." Nerve irritation undoubtedly is the cause of 
sexual perversion (outside of heredity and malformation) so their relief 
is as necessary to bring about reform of habits as to effect a cure. Where 
the general health is affected constitutional treatment should follow. 
Motschutkovsky uses suspension in treating these cases with good re- 
sults. The effect is to separate the vertebrae, freeing spinal nerve and 
blood channels. The prostate will probably be found in an irritated, 
sensitive condition, as well as the seminal vesicles. Treat as outlined 
under the prostate gland. Ligation of the dorsal vein of the penis is 
recommended by some authorities as tending to aid turgescence of the 
organ. Prognosis is so dependent on how well the patient follows di- 
rections, age, environment and general condition that it is hard to give, 
but as a rule is rather favorable. 

Traumatic Impotency is a strictly osteopathic classification, for 
the reason that sexual weakness is often traced to lesions resulting from 
remote injuries. These injuries may be to the spine, ribs or sacrum. 
The lower spine may be impacted from a fall or the result of long con- 
tinued riding on rough streets or the railway. This inhibits the nerve 
supply to the extent of often seriously impairing the sexual functions. 
If the cord is injured to any extent the results are more serious. Treat- 
ment in these cases has given uniformly good results. It will always 
be due to a specific lesion, so the examination must be thorough. 

Psychic Impotency is the form most frequently met with and gen- 
erally the most difficult to cure, yet it should not be if the patient's con- 
fidence can be secured, for in many cases sexual power is but sUghtly 
impaired, but owing to the suggestions given by the medical advertisers 
the victim diagnoses his own case as hopeless. "It is not uncommon 
that virility returns with the peace of mind. "^ Observe all the procedure 
1. Vecki, Sexual Impotence. 



The Practice of Osteopathy 179 

given and then inspire hope where it can be honestly given, and if the 
patient is progressing favorably, other things being equal, advise early 
marriage under strict rules of conduct. If already married, conjugal re- 
lations should be most carefully investigated and the wife taken into your 
confidence. Her co-operation in correcting very possible errors in sex- 
ual matters, as well as sympathetic aid in easing the patient's anxiety 
and chagrin, will be invaluable. Nothing but the frankest understand- 
ing between all parties is permissible and the osteopath must be in ab- 
solute control. 

Organic Impotency is the result of a cortical injury or disease. 
The latter is the most common, as it follows tabes dorsalis, paralysis 
affecting the lumbar cord, some cases of diabetes, etc. Also, any con- 
genital malformations or absence of all or part of the organs. Prog- 
nosis in these cases is bad, as cure is seldom possible. 

In no other class of cases will honesty, tact and good judgment 
count for sO much or the rewards be greater. 



180 The Practice of Osteopathy 

HEAT STROKE 

(Heat Exhaustion: Sunstroke) 

An affection produced by exposure to excessive heat. Two varieties 
are recognized; heat exhaustion and thermic fever. 

Heat Exhaustion. — This is caused by prolonged exposure to high 
temperatures, combined with physical exertion. Fatigue, over-eating, 
alcohoHc drinking, and poor sanitation predispose. This may occur 
without exposure to the direct rays of the sun, the heat being artificial, 
or in mid-summer, in close, confined rooms the same result will be pro- 
duced. There is vasomotor paralysis, the surface of the body is usually 
cool, the temperature may be as low as 95 degrees F., while the pulse 
is small and rapid. 

Sunstroke or Thermic Fever. — This is usually caused by pro- 
longed work under the direct rays of the sun in a humid, very hot and 
sultry atmosphere. This is caused by the action of the heat upon the 
heart centers producing a paralysis of those centers. 

Pathologically, rigor mortis develops early and is marked. Putre- 
factive changes appear early, owing to the high temperature of the ca- 
daver. The various organs are deeply congested, the venous engorge- 
ment is extreme in the cerebrum. There is rigid contraction of the left 
ventricle; while the right is dilated and filled with blood. The blood is 
fluid and dark. Parenchymatous changes take place in the liver and 
kidneys. 

In heat exhaustion with lowered temperature there is a paralysis of 
the vasomotor center in the medulla, and the heat is dissipated more 
rapidly than it is produced. In thermic fever the heat regulating centers 
become paralyzed by the action of the excessive temperature and more 
heat is produced^ and less dissipated than normal. 

Symptoms.— Heat Exhaustion.— This may occur gradually or 
suddenly with a severe attack of faintness, pallor, dizziness, headache, 
cold perspiration and sometimes bhndness as the first symptoms. Con- 
sciousness is rarely entirely lost. In severe cases there is more permanent 
collapse. The pulse is rapid and feeble and there is great restlessness 
and dehrium. Under prompt treatment mild cases may recover in a 
few hours, while in extreme cases death may occur almost at once from 
heart failure. 

Thermic Fever. — In some cases the patient is struck down, be- 
comes quickly unconscious, and may die within an hour, or death may 



The Practice of Osteopathy 181 

be almost instantaneous. In other cases there is pain in the head, op- 
pression, dizziness, nausea, vomiting and sometimes diarrhea or frequent 
micturition. Soon unconsciousness sets in, the face is flushed, the eyes 
injected, the breatliing labored and there is a temperature of from 105° to 
110° F. The pulse is full and rapid, the skin hot and dry and the pupils 
are contracted. There is usually complete relaxation of the muscles, 
and in some cases there is twitching and jactitation. Epileptiform con- 
vulsions are rare. In fatal cases the coma deepens, the pulse becomes 
feeble, rapid and irregular, the breathing hurried and shallow and death 
occurs in a few hours. Favorable cases are indicated by a fall in the 
temperature and by the return of consciousness. In these cases recov- 
ery may be complete. In some cases the patient may never be able to 
stand even moderate degrees of temperature, which often produce excite- 
ment, headache and pain in the cervical region. Failure of the memory, 
and the loss of power to concentrate the mind are sometimes sequelae. 
Meningitis, epilepsy and insanity are also sequelae. 

Diagnosis. — This presents little difficulty. The history and cir- 
cumstances preceding the attack are very important in making the diag- 
nosis. The diagnosis between heat exhaustion and sunstroke fever is 
readily made. In heat exhaustion the temperature is lowered, the 
pulse is feeble, consciousness is rarely completely lost; in sunstroke fever 
the temperature is extremely high, there is usually complete unconscious- 
ness, and the pulse is full and rapid. 

Prognosis.- — This should be guarded, depending upon the severity 
of the case. 

Treatment. — ^In cases of heat exhaustion remove the patient to 
a shad}^ place and apply water to the face, chest and spine. Thoroughly 
treat the upper cervical region, in order to control the impaired vasomotor 
centers and nerves. If the temperature is below normal a hot bath should 
be given. Keep the heart and lungs stimulated. 

In sunstroke, place the patient in a recumbent position and loosen 
all constricted clothing, and stimulate the heart's action. The high 
fever is to be met promptly. Place the patient in a bath of water, to 
which add ice freely. The patient may also be rubbed with ice, and ice 
water enemata may be employed. The muscles of the neck will be found 
contracted, probably due to cerebral hyperemia. A thorough relaxation 
of these muscles will be of gi-eat aid in equalizing the vascular system. It 
is a good plan to thoroughly relax all the muscles along the spinal colunm 
for the same purpose. When the temperature nears normal the baths 
should be stopped. After the temperature has been reduced place the 



182 The Practice of Osteopathy 

patient upon a cot with ice to the head. The cervical treatment should 
be repeated as often as necessary. The diet of the patient should be 
liquid for a few days. Plenty of water and stimulation of the kidnej^s 
and bowels will be found beneficial. The sequelae are to be treated ac- 
cording to the condition. Much can be done for the sequelae of heat ex- 
haustion and sunstroke. Lesions will be found corresponding to the 
regions involved. Deep contracted muscles are common. 



The Practice of Osteopathy 183 

DEPARTMENT OF OPHTHALMOLOGY 

By C. C. Reid 

It is the desii-e to make this discussion on the eye the most useful 
possible to the whole profession. Let it be plainly understood that 
there is no effort to cover every phase of eye pathology but to elaborate 
eye diseases and therapeutics strictly from the standpoint of osteopathy. 
There are many very elaborate and extensive text-books and even ency- 
clopedise written on the eye by the medical profession. The world of 
ophthalmic literatm-e is extensive and profound. Just so are the elab- 
orations on the' general field of medicine. Such things as hereditary in- 
fluences, congenital deformities, amblyopias, albinism, coloboma and the 
field of ophthalmic surgery does not concern us at the present time in 
an osteopathic text-book. This department is dedicated to a scien- 
tific development of ophthalmic therapeutics along osteopathic lines of 
thought. Some things in the therapeutics of the eye concern all schools 
alike. For instance, proper cleanliness and antiseptic precautions in 
regard to the eye, dietetics, hygiene and the care of the general health. 
The same anatomy and many of the same methods of examination and 
diagnosis obtain ui all schools. It is the intention to go into the opthhal- 
mic therapeutic field in these discussions where osteopathy has a differ- 
ent outlook with a definite distinct reform to offer in the viewpoint of 
the anatomy, methods of diagnosis and the system of treatment. 

How to Examine an Eye 

It has been said that one should be a good general man in order tc 
be a competent specialist. This is especially true in regard to ophthalmic 
therapeutics. Many systemic diseases have eye symptoms and path- 
ology. The same blood and lymph that nourishes and bathes different 
parts of the body, also circulates in the structures of the eye. In 
the examination of the eye, heredity, occupation and envnonment 
are to be taken into consideration. Osteopathic lesions may exist from 
falls, strains, twists, blows, colds and exposure and impair the mtegrity 
of the metabolic processes of the eye through the nerve connections and 
blood supply and lay the foundation for a great variety of eye diseases. 
With these lesions existing about the neck and upper dorsal, it is only 
required to have some insignificant local irritant to start symptoms and 
cause pathology apparently out of all proportion to the etiology. It is im- 
portant then that one understand the nerve centers and reflexes and the 



184 The Practice of Osteopathy 

osteopathic logic underlying these conditions or else he must frequently 
work without a satisfactory explanation of the etiology and consequently 
be more or less unscientific in his treatment. 

The eye examination should consist of the case history, the family 
history, inspection, osteopathic examination, especially from the fourth 
dorsal vertebra to the occiput and especial exiimination of the eye by 
inspection and other methods. 

1. The Case History. Thoroughness of the doctor, or the lack of 
it, will be readily displayed at this point. Every little thing, as far as 
oossible, that has a bearing on the case should be observed and uncov- 
sred in the case history. The physician should want to know every fact 
that helps him to better understand his case. Patience in hearing the 
history will often be of great assistance. It gives light on the physical 
and mental condition of the patient. Much can be gained by being 
careful and attentive. Notice carefully what he emphasizes and what 
he thinks is the most important. Inquire in regard to headaches, ner- 
vous symptoms, previous eye trouble and past illnesses. Get a venereal 
history if present, as many eye diseases are complicated or caused by 
syphilis or gonorrhea. 

2. The Family History. — Inquire as to blindness in the family 
and about the age it occurred, if any. Get a venereal history if possible. 

3. Inspection. — Much inspection can go on while the history is 
being taken. Observe the countenance, whether there is strabismus or 
frowning due to eye strain, photophobia as suggested by the effort to 
avoid the light; note symmetry. Look closel}' at the lashes, lids, con- 
junctiva, cornea and iris. Note any scales or crusts on the lids at the 
root of the lashes. Turn the lids for further inspection. Note the size 
and relation of the eyes. Exophthalmos may be due to an enlarged 
globe in high myopia, to Graves' disease, orbital tumor and paralysis 
of the extrinsic muscles, or staphyloma. In blepharospasm there may 
be a corneal ulcer or a rupture of the eye-ball. An exact examination 
must be made at the first visit in order for a diagnosis to institute the 
best treatment possible. Study the conjunctival sac for congestions, 
hypertrophy, swelling, tumors, foreign bodies, trachoma bodies and 
secretions. In all forms of conjunctivitis the congestion is most marked 
in the fornix and decreases toward the sclerocorneal junction. In iritis 
and cyclitis there is a circumcorneal injection, a pink or red color radiat- 
ing from the cornea. Note any corneal pathology in the way of ulcers 
or abrasions and foreign bodies. Compare the tension of the eyes. 

4. The Osteopathic Examination of the Eye. — This heading is 



The Practice of Osteopathy 185 

put here in order to show what osteopathy has to offer that is distinct as 
belonging to our system and not practiced by any other school. Osteo- 
pathic research so far has shown that osteopathic science has much to 
offer on etiology and diagnosis and treatment in eye diseases. The 
case history, family history and inspection should require but a few 
minutes but they are essential to a proper examination and may aid us 
in what to expect osteopathically. Weak nerves will cause asthenopia. 
A broken arch, an innominate lesion or a slipped axis may cause weak 
nerves. The osteopathic eye examination then should consider the 
whole mechanism of the body. In case glasses are being worn for asthe- 
nopia they may readily be made unnecessary by osteopathic treatment 
in the correction of the lesions and building up the system. Some time 
ago some parents sent their daughter to me to have her eyes fitted for 
glasses. They stated that she had been to different doctors and opticians 
and no one had ever given satisfaction. They said she was all right every 
other way if her eyes were properly fitted with glasses. They did not 
want her examined or treated otherwise because she would be well every 
other way with correct glasses. Her vision was right eye 5-20, left eye 
5-15 or about one-fom^th vision in each eye. A plus .87 diopter sphere 
combined with a plus 3 diopter cylinder in axis 90 gave her perfectly 
normal 5-5 vision in each eye. This gave her perfect satisfaction until 
she started to school in September, a couple of months later. Before 
the end of the first month she was having trouble with her eyes and was 
again sent to me by her parents. Her v^ision was reduced to 6-15 in each 
€ye with her glasses on. She wondered and no doubt the parents did, if 
it was not another case of a misfit in glasses similar to all her previous 
experiences. This time I insisted upon a thorough physical examina- 
tion against all protest. The following lesions were discovered: the 
left innominate was up and back or tilted posteriorly, first lumbar anter- 
ior and to the right, sixth and first dorsals to the right. The case was not 
refracted again. I took particular care the first time and I was quite sure 
the refractive error was corrected. It was all explained to the parents 
and regular osteopathic treatment was begun. In less than a month 
practically every lesion was corrected, her vision returned to normal and 
she also was cured of an annoying backache with which she had been 
bothered for years. Her nerves were depleted a great deal. She got 
benefit in ways that she had not dreamed of. This approach to the 
eye is not considered by physicians in general, even the oculists. I have 
had about ten special courses in medical colleges and hospitals on the 
eye, ear, nose and throat, and I have never heard anything mentioned 



186 The Practice of Osteopathy 

that would indicate any ideas of the logic involved in this case. Surely 
osteopathy has much to offer in eye troubles that is new and unique. The 
osteopathic examination of the eye then should begin with the feet, goins 
then to the innominates, lumbar, dorsal, ribs and cervical regions. Ocu- 
lists are too prone to rely upon crutches (glasses) in the treatment of 
asthenopia. 

It is easy for the osteopath to conceive how lesions of the upper 
dorsal and cerAdcal regions may occur and disturb the nerve and blood 
supply to the eye. This is why asthenopia appears so frequently with 
ordinary use of the eyes, even without abuse or refractive errors. 

The Lumbar Region 

The lumbar region should bs rarefuUy examined, especially for any 
curvature which might cause a disturbance of the equilibrium above. 
Compensatory curv^ss or individual lesions would be the result with a 
consequent interference with the integi'ity of the nervous reflexes to the 
eye. 

The Dorsal Region 

The same may be said of the dorsal region as of the lumbar in re- 
gard to curvatures. There is one individual lesion in this region that 
very frequently exists with eye troubles, i. e., the 2nd dorsal vertebra 
lateral. Any of the upper four dorsals in lesion maybe a causative factor 
in predisposing to disease of the eye but it has been my observation that 
the 2nd is involved most often. In severe headaches due to eye strain 
from refractive error, a good diagnostic symptom is tenderness and con- 
traction at the 2nd dorsal even when there is no subluxation. 

The Cervical Region 

This region should have particular care in search for individual 
lesions. It is quite easy to pass over some small cervical lesion that 
may be causing serious disturbance, especially if the neck happens to 
be fleshy. I have corrected cervical lesions and stopped twitching of 
the eyelids (orbicularis palpebrarum) and other muscles about the face. 

The first case I ever saw was twenty-two years ago when I was a 
junior at Kirksville. Dr. F. P. Millard, now of Toronto, was a room 
mate of mine. He was constantly annoyed by a twitchmg of an eyelid. 
I did not find any lesion for it. We went one day to see Dr. Still at his 
home and told him of our difficulty. He said without examination that 
the 3rd cervical was in lesion. There was a senior student present whom 
the "Old Doctor" directed how to use the proper technique. There was 



The Practice of Osteopathy 187 

a sharp pop, the vertebra evidently went into right relation, the twitch- 
ing stopped. I understand the patient has had very little trouble since. 
Injuries, exposure and strains to the spine may have antedated an 
innominate lesion and caused weak joints, muscular and ligamentous 
tension, local inflammations and partial immobilization of joints. All 
this would have its modifying effects upon the manifestation of secondary 
lesions from the innominate abnormality. This makes the study of the 
bony relations very complex and the effect upon the numerous blood 
vessels, nerves and other soft tissues still more complicated. 

The Ciliospinal Center 

Following osteopathic examination and giving proper importance to 
lesions below the fourth dorsal vertebra, we must remember a special 
significance to be attached to lesions of the upper dorsal in relation to 
the eye. 

Almost any author on nervous diseases or diagnosis will discuss this 
center. Many of us have it not sufficiently impressed, hence I repeat 
some known relations. The ciliospinal center consists of a nuclear 
group of cells in the lateral horn of the last cervical and two upper dorsal 
segments of the spinal cord. From this nucleus fibers pass to the anter- 
ior division of the eighth cervical and first and second dorsal nerves and 
become the white rami communicantes which are efferent in their func- 
tion. These fibers pass to the inferior cervical sympathetic ganglion, 
thence upward with the sympathetic trunk through the middle and 
superior cervical sympathetic ganglia, along the carotid plexus to 
the vessels of the face and eye, to the glands of that region, to the un- 
striped muscular fibers of the levator palpebrse superioris and to the 
dilator pupillae muscle. 

Any strong feeling or emotion (which of course is perceived and in- 
terpreted by the brain cortex) will cause a dilatation of the pupil of the 
eye. The cervical sympathetic being cut, dilatation does not take place. 
The rami of the cervical, first and second dorsal cut, the phenomenon 
stops. It is evident the ciliospinal center is under the influence of a 
center or centers in the brain. Bing says "There is even an idiomotor 
mydriasis, which may be brought about by a ver3^ vivid mental concep- 
tion of darkness. " 

It has been noted that paralyzing lesions of the cervical sympathetic, 
of the last cervical and two upper dorsal segments of the cord, and of the 
anterior roots and rami communicantes of the same, will result in myosis. 



188 The Practice of Osteopathy 

The efferent rami are also vasomotor, secretory and trophic. It 
must necessarily follow that congestive and inflammatory conditions, 
secretory perversion of the lachrymal, Meibomian, Zeissian and perspira- 
tory glands, and disturbance of the normal nutrition of any of the orbital 
tissues may result from lesions of the lower cervical and upper dorsal 
vertebrae. 

Osteopathically we know that such a lesion may not be sufficient to 
be paralytic in its effect, but stimulatory. In this case we may note a 
pupil habitually too wide and more or less photophobia from a super- 
abundance of light. The unstriped muscle fibers in the levator palpebrse 
superioris may be unduly contracted making an appearance of a slightly 
bulging eyeball when it is only a wide open eye. 

One who has eye strain from a refractive error, overuse of the eyes, 
or unbalanced muscles will as a rule have tenderness at some spot in the 
region of the ciliospinal center. A mechanical lesion at that part 
of the spine may or may not exist in such conditions, but I believe the 
soreness is there every time. This is one of the diagnostic points in 
differentiating headache of eye strain from other conditions. 

White rami are only in the dorsal region and to the second lumbar 
and from the second, third and fourth sacral. It has been noted that 
lesions of the cervical vertebrae do not have as profound an effect upon 
the eyes as do lesions of the first three dorsal vertebrae. The plausible 
explanation of that is that the cervical vertebrae have no white rami 
from their corresponding nerves in the bulbo-spino-sympathetic-ciliary 
arc as have the upper dorsal. 

From all the foregoing statements one can readily contemplate the 
intricate complexity of our osteopathic problems in relation to the eye. 
Combine this logic of the lesions outlined and the ramifications of the 
structures with their normal and perverted functions and combine it 
with contributing causes, such as infection, exposure, irritants, etc., and 
amidst the great diversity we reduce much miscellaneous, unclassified 
material to a degree of simpHcity. Many otherwise unexplainable con- 
ditions become reasonably clear. 

Dr. Louisa Burns under "The Experimental Demonstration of 
Osteopathic Centers" has this to say: 

'^Somatic Reflexes" 

"In the first series of experiments, the electrodes were placed upon 
the nasal mucous membrane of animals under anesthesia. The muscles 
near the third thoracic vertebra were at once strongly contracted 



The Practice of Osteopathy 189 

"The electrodes were then placed upon the conjunctivae. The muscles 
near the second vertebra were then contracted. There were also slight 
and inconstant contractions of the cervical muscles 

"The electrodes were placed upon the eye ball. The muscular con- 
tractions were sometimes noted near the second thoracic vertebra, but 
the reaction was not constant. The cervical muscles were scarcely 
contracted at all. 

"The electrodes were placed upon the outer surface of the eye lids. 
The facial muscles were contracted very quickly and forcibly, but no 
contraction of the muscles of the upper dorsal region were noted 

"The superior cervical ganglion was exposed to view, and the 
electrodes placed upon it. The pupils became greatly dilated, the con- 
junctivae beoime hghter in color, and the mucous membranes of the nose 
and throat were also lightened 

"The Gasserian ganglion was exposed to view. The ganglion 
was stimulated directly. The upper thoracic muscles were very strongly 
contracted, and the blood vessels in the area of the distribution of the 
fifth nerve were immediately and strongly contracted. Some of the 
sjrmpathetic fibers are carried by way of the fifth nerve. In order to ex- 
clude the effect of the direct stimulation of these fibers, the fifth nerve 
was cut, and the central end was stimulated by the electrodes. The 
muscles of the upper thoracic region were contracted, as before. The 
vessels in the area of distribution of the fifth nerve were contracted after 
latent period of a minute or so 

"The stimulation of the central end of the cut fifth nerve caused 
strong muscular contractions in the upper thoracic region, and also 
constriction of the vessels in the area of distribution of the fifth. Direct 
stimulation of the superior cervical ganglion produced effects identical 
with those produced before the mutilation. 

"The spinal cord was cut above and below the superior cervical 
ganglion. This cut was made from behind, and the sympathetic chain 
was uninjured. The effects noted after both operations were the same, 
and can be described as one. 

"The stimulation of any cranial structure failed to cause reflex 
contraction of the muscles in the upper dorsal or the cervical region. 

"Stimulation of the cranial structures did not produce any vascular 
changes except those which might be referred to the direct effects of the 
electricity upon the vessel walls. 



190 The Practice of Osteopathy 

"Direct stimulation of the superior cervical ganglion produced 
the effects noted before mutilation. 

"Therefore the cervical portion of the spinal cord is an essential 
element of the reflex arc by way of which sensory impulses from the 
cranial structures are able to affect the condition of the upper dorsal 
muscles, and also in the path by which these impulses are able to affect 
the size of the blood vessels of the cranial structures themselves 

"Mechanical stimulation of the tissues near the second thoracic 
spine was followed by a contraction of the blood vessels of the cranial 
mucous membranes and the conjunctivae, by a dilatation of the pupils, 
and an increased secretion of saUva. These effects were practically in- 
variable 

"The superior cervical ganglion was subjected to mechanical stim- 
ulation by the manipulation of the tissues over it. In animals, this 
maneuver was followed by dilatation of the pupils and by a contraction 
of the cranial vessels, which was soon followed, if the stimulation con- 
tinued, by a dilatation which was rather persistent. 

"After the extirpation of the Gasserian ganglion without the 
injury of the sympathetic nerves, the mechanical stimulation of the 
tissues near the second and third thoracic vertebrae caused the same vaso- 
constriction and pupilo-dilation as was observed in the animal before 
mutilation. 

"After the destruction of the cervical portion of the sympathetic 
chain, and after the extirpation of the Gasserian ganglion in most ani- 
mals, the mechanical stimulation of the tissues in the upper dorsal region 
did not produce any perceptible effects 

"Mechanical stimulation of the tissues near the second and third 
thoracic spines caused dilatation of the pupils and contraction of the 
vessels of the cranial mucous membranes. 

"Inhibition, or the maintenance of an artificial lesion, caused dila- 
tation of the vessels of the nasal mucous membranes and of the con- 
junctivffi. The eye ball was also somewhat congested. The pupils 
were dilated in tliis case also." 

The Nose and Throat in Eye Trouble 

An examination of the eye would not be complete without a careful 
inspection of the nose and throat. The same nerve and blood supply 
that go to the eye is tied up so definitely with the nose and throat that 
when there are lesions of the nose and throat the eye is often affected 



The Practice op Osteopathy 191 

secondarily. Just recently a case of dacryocystitis came into my 
office. After I had carefully examined her eye, spine, nose and throat, 
she informed me that she had been to three eye speciaHsts before and not 
one of them had ever looked at her nose and throat, not to mention the 
spine. She had cervical and dorsal lesions, and diseased tonsils. The 
inferior turbinate on the side of the dacryocystitis was curled out so 
that it lay against the external wall of the nose almost if not altogether 
blocking the entrance of the lacrymal duct to the inferior meatus. 
This was evidently the predisposing cause of her dacryocystitis. 

In neuralgia of the eye, blepharitis, obscure pain, conjunc- 
tivitis and often deeper troubles you will find a bad condition of the 
nasopharynx, such as adenoids, vegetations, pus pockets, adhesions 
in the fossa of Rosenmuller, contraction of the soft palate, disturbed re- 
lations of the septum and turbinates, sinus trouble, poor drainage, ex- 
ostoses and polyps. In eye disease all these things should be discovered 
if they are present, in order to get best results and in order to make a 
careful diagnosis. 

Examination of the Eye by Special Methods 

The first thing after the family history, personal history, inspection 
of the eye and the osteopathic examination, is to find out how well the 
patient can see. To test the acuteness of vision certain test letters are 
used. Snellen's Test Letters are good. The normal eye can read 3-8 
inch letters at twenty feet. The test letters on the cards usually range in 
size to be read at 10, 15, 20, 30, 40, 50, 70, 100 and 200 feet. The most 
desirable distance is 20 feet. If at the distance of twenty feet he reads 
the 3-8 inch letters his acuteness of vision would be marked 20-20 or 
normal. Always use the distance between patient and chart as the 
numerator of the fraction and the number above the letters which he 
reads as the denominator. If he is twenty feet away, the numerator re- 
mains twenty and the denominator changes according to the line of letters 
seen on the test cards thus: 20-15, 20-30, 20-70, or 20-200 may express 
the vision. If the patient could not see the 200 feet letters at 20 feet he 
must be brought nearer, say 10 feet, for him to see the large letters; his 
vision would be 10-200. These fractions representing the acuteness of 
vision may be expressed in meters. Some charts have letters numbered 
that way. 

If the vision is good enough for small objects to be clear, the near 
point should be taken. This would show the amount of accommodation 
of the eye. This is expressed in diopters. 



192 The Practice of Osteopathy 

A diopter is the unit of measurement of the refractive power of 
lenses. Leases are numbered by their refractive power in diopters. A 
lens that ha^ a curvature that will refract parallel rays of light and bring 
them to a focus at one meter distance is said to be a one diopter lens. 
This unit of measurement for the refractive power of lenses was proposed 
by Nagel in 1866. It soon became quite generally used. 

The focal distance of a lens decreases as the strength of a lens in- 
creases. One diopter lens (written ID) has a focus of one meter (1 M) 
or 100 cm distance. A 2 D lens has a focal distance of 1-2 M or 50 cm. 
A 4 D lens has 25 cm focal distance and a 1-2 D lens has 100 cm-f- | = 200 
cm distance or 2 M. Trial cases have in them lenses varying in strength 
from .12 D or .25 D to 20 D of the spheric form. We will not discuss 
the trial case here. 

Accommodation in the Eye 

Accommodation in the eye is the ability of the eye to vary its 
focal point. Wlien the normal eye (emmetropic) is at rest its focal point 
is at infinity so far as parallel rays are concerned. This is called the far- 
point or the "punctum remotum** (P. R.), 

When the eye looks at letters twenty feet away it scarcely accom- 
modates at all to get a focus, or so Httle that it may be disregarded in 
ordinary practice. Now if one brings fine print close to the eye he will 
find a point so close that it becomes indistinct. This point is the near- 
point of focus or the "punctum proximum" (P. P.). The range of 
accommodation is the difference between the refractive power of the eye 
when it is at rest and whan the accommodation is exerted to the utmost, 
the difference between the P. R. and the P. P. 

If one must accommodate one diopter to get a focus at one meter 
or forty inches distance, at thirteen inches or reading distance one must 
accommodate at least 3 D in order to see the letters clearly. If 3 D were 
the total of his accommodation he could not read at that distance but a 
few minutes; because the accommodation could not be held at its maxi- 
mum for long at a time. Eye strain with its train of symptoms would 
result. Hence it is quite important to find the near-pomt or punctum 
proximum in order to judge in regard to eye strain in an emmetropic eye. 
If there is a refractive error, allowance for it must be made accordingly. 

As a person gets older the accommodation in the eye becomes less 
and less until at 45 years of age he can only use 4 to 5 D of accommoda- 
tion. This is so close to the amount required for reading that he has 
some eye strain. He begins to hold his paper farther away from him so 



The Practice of Osteopathy 193 

he requires less accommodation. This condition we call "old sight" or 
presbyopia. An emmetropic eye at forty-five to fifty years of age re- 
quires a plus glass to make up for some accommodation in reading. 

Frequently there are latent disturbances of equihbrium of the ex- 
trinsic muscles of the eye. This is heterophoria. If it is a latent con- 
vergence it is esophoria; if a latent divergence it is exophoria. The 
latter is more frequent. Hyper- and hypophoria are used for upward or 
downward tendencies. Normal muscular balance is orthophoria. 

Cause the patient to fix on an object about thirteen inches away 
with both eyes; push a sheet of paper in front of one eye and watch be- 
hind the paper, the eye thus covered. If heterophoria exists the eye will 
move sUghtly from its point of fixation since it no longer sees the object. 
In orthophoria it will remain fixed as long as the other eye sees the ob ect ; 
the innervation to the different muscles is properly distributed. 

A Maddox rod found in any complete trial case may be placed before 
one eye. Have the patient fix on a candle flame, say twenty feet away. 
The flame appears drawn out into a luminous line. This line can not 
be fused with the candle flame as the other eye sees it if there is hetero- 
phoria. The amount and kind of disturbance is somewhat indicated by 
the distance and direction of the luminous line and the flame. The ex- 
act amount can be measured by the use of a prism that will cause them 
to fuse. 

Next the patient should be taken to the dark room and a careful 
inspection of the anterior segment of the eye should be made with oblique 
iUumination. First use the unaided eye, then use a lens that magnifies. 
The 20 D plus lens from your trial case will suffice for the magnification. 
Note the transparency or lack of it in the cornea and crystalline lens; 
the depth of the anterior chamber and the appearance of the pupil and 
iris. Now we are ready for the ophthalmoscopic examination. 

The Ophthalmoscope. — This is an instrument that commands 
great respect. Any one who is interested in eye troubles must have and 
use the ophthalmoscope if he expects to be efficient in diagnosis, upon 
which, of course, intelKgent treatment must forever depend. One must 
try and try again in order to become proicient in the use of the oph- 
thalmoscope. 

A Schematic Eye is of great assistance to a beginner who does not 
have clinics or patients on whom to practice. Such an eye with full di- 
rections can be obtained at almost any optical goods store. It will make 
the study of ophthalmoscopy easy and interesting. The pupil can 



194 The Practice of Osteopathy 

be regulated to any size and the eye can be made short (hyperopic), long 
(myopic) or normal (emmetropic) for study. 

The efficient use of the ophthalmoscope makes the diagnosis of in- 
ternal diseases of the eye as easy as the diagnosis of external diseases of 
the eye. Only some rare conditions will puzzle, and that is true of any 
part of the anatomy. 

The ophthalmoscope is a simple instrument; its chief function is 
to illuminate the interior of the eye. The value of ophthalmoscopic 
findings depends on their correct interpretation by the examiner. 

The ophthalmoscope has a mirror to reflect the light into the eye. 
It has two discs on which are mounted convex (plus) and concave (min- 
us) lenses. The larger disc has seven plus and eight minus lenses. To 
these may be added the lenses in the smaller disc making many com- 
binations. 

A drop of a 2% solution of cocaine or homatropine may be used as a 
mydriatic where one can not otherwise see clearly the fundus. If no 
mydriatic is used a somewhat weak illumination should be employed 
in order not to arouse the accommodation to much activity and make the 
pupil small. If there is any opacity in the media a strong illumination 
should be used. The room should be dark; the darker the better. 

There are two methods of using the ophthalmoscope. The in- 
direct and the direct methods. One is more useful at one time and the 
other at another time. By the indirect method we view the whole field 
of the fundus more readily but less in detail. With the ophthalmoscope 
before his eye the examiner's face is twelve to fifteen inches from that of 
the patient. When the '**red reflex" of the eye is seen a plus 13 or 
16 D lens is interposed near the patient's eye. This magnifies the field. 
The image is inverted. As a rule it is best seen with a +4 D lens in the 
aperture of the ophthalmoscope. 

This method is especially more satisfactory in high degrees of my- 
opia and astigmatism. The optic disc is the objective point. One 
may see a retinal vessel first; this should be followed to its emergence 
from the disc. From this point view all parts of the fundus by having 
the patient look in different directions. This is better by the indirect 
method than for the examiner to vaiy his position. 

The direct method of ophthahnoscopy is better for detail work and 
in all cases except high degrees of myopia and astigmatism. It is also 
better in determining errors of refraction. The patient looks straight 
across the room. For a beginner it may be essential to dilate the pupil, 
hence the schematic eye as suggested. 



The Practice of Osteopathy 195 

If the examiner has a refractive error, he should wear his own glasses 
or correct by throwing in front of his eye proper lenses in the ophthal- 
moscope. Face the patient and sit on the side of the eye to be examined. 
Use left eye to examine the patiet's left eye and right eye for the pa- 
tient's right. Examiner and patient keep both eyes open. The ex- 
aminer may not be able to suppress the image of his other eye and may 
have to close it part of the time. Catch the ''red reflex" some 15 to 
18 inches away and move close to the patient's eye. The "red reflex" 
color varies with the error of refraction, the transparency of the media, 
the degree of pigmentation and the size of the pupil. A blood clot will 
make it redder, some exudates will make it gray or yellow. 

The examiner may approach as close as half an inch from the eye 
to be examined. Find the optic disc and examine all points of the fun- 
dus from it. Rotate in glasses to correct the patient's refractive error if 
he has any. The strongest plus glass with which the fine retinal vessels 
can be clearly seen will represent the hyperopia of the eye. This is 
true only if the examiner's accommodation is at rest. The weakest 
minus glass with which the fine retinal vessels can be clearly seen repre- 
sents the myopia. 

A Normal Fundus. — The color of the fundus is due to the blood 
vessels of the retina and choroid and the connective tissue of the chor- 
roid and sclera. Variation is due to the pigment. In the albino it is 
Kght pink. In the negro it is dark reddish. There are all gradations 
between the two. 

The optic disc is the end of the optic nerve as it comes into the 
eye; it is circular in shape, pink in color, and sharply defined. It is 
about l-16th of an inch in diameter; about 15° to the nasal side of the 
pole of the eye and slightly above the horizontal. There may be a dark 
choroidal ring around the disc or part way around. There may also 
be a white ring caused by the sclera. As a rule there is a depression in 
the center of the disc out of which the retinal vessels emerge and spread 
out over the fundus. 

The fovea centralis or point of clearest vision is located two and 
a half disc diameters to the temporal side of the disc. Around this is a 
circular area of Hght yellow, the macula lutea. 

The subject of ophthalmoscopy has been touched upon somewhat 
in detail because of its great importance to the general practitioner. 
Every osteopathic physician should know the ophthalmoscope well 
enough to recognize the ordinary lesions inside the eye. When we take 
up pathological conditions of the eye we will have occasion frequently 



196 The Practice of Osteopathy 

to refer to the ophthalmoscopic appearance. Without the use of this 
instrument aU of our cUnical field research on internal diseases of the 
eye is valueless. Many have told me they have cured cataract with 
osteopathic treatment, some say they have cured specific neuroretinitis 
with no sequelae, others testify to opacities and bhndness from various 
causes. Invariably we ask if they used the ophthahnoscope in their 
diagnosis and with it watched the progress of the case. Abiiost invari- 
ably the answer is "no, it looked hke it," "the s>Tnptoms indicated it," 
or "Dr. so and so, an ocuhst diagnosed it as such." Fellow Osteopaths! 
we can not base our claims on this kind of data. With a little study and 
practice the ophthalmoscope can be mastered. Not till then can we get 
reHable statistics on internal diseases of the eye in our case reports. Os- 
teopathy has much to reveal to us in this field and for the sake of the 
science and our patients we appeal to every one to do the work here set 
forth. 

Diseases of the Eye 
Osteopathic Manipulation for Eye Diseases 

A general correction of lesions should be made in order to give per- 
fect aligmnent and equilibrium. Lesions that affect the nerve and blood 
suppl}^ will be found from the fourth thoracic to the occiput ; more often 
at the occiput, atlas and axis in the cervical region and the second and 
third thoracic in the dorsal region including the ribs. 

Correction of these lesions must have specific attention in every case 
of eye disease that shows any tendency to chronicity or in repeated eye 
disease and exacerbations. 

A thorough upper spinal treatment to insure good mobility of all 
joints and establish freedom of fluids and forces is recommended. 

The nose, throat and sinuses should be examined for pathology. 
If the tonsils and pharynx are not normal the cotted index finger should 
be introduced into the mouth until the anterior pillar of the fauces is 
reached. A mouth gag may or may not be used. Massage the tonsil 
through the anterior pillar then move to the top and press down on the 
tonsil with a pumping motion. Repeat this from below the tonsil and 
posteriorly. Slip the finger under the soft palate and stretch it thor- 
oughly. Clean out any adhesions and vegetations in the vault of the 
nasopharynx and fossa of RosenmuUer. Stretch the pillars of the fauces 
by pressing down on each side at the root of the tongue. 

If the sinuses are diseased they should be drained. If the nose is dis- 
eased and has abundance of secretion, first use irrigation for cleanhness. 



The Pkactice of Osteopathy 197 

Manipulation in the nose will be of great benefit in some eye dis- 
eases as pa,thology there frequently has an important bearing on diseases 
of the eye. The nose is often too narrow and contracted. The first inch 
of the nose is muscular and cartilaginous; it is of even more importance to 
dilate the nose in contractured conditions than it is the sphincters at the 
lower end of the rectum. The great benefit derived from rectal dila- 
tation has been recognized for years. 

In dilating the contracted nose a wide blade nasal speculum may be 
used. The cotted and oiled httle finger may be used where it is properly 
adapted in size. The dilating can be done with practically no pain and 
no damage to membranes or other tissues. It should not be extended 
beyond the cartilaginous and muscular part. Manipulation of the 
turbinates and tissue further back may be done if needed, by the use of 
instruments. The Edwards turbinate adjuster instrumefnt (Aloe Co., 
St. Louis) or the Ruddy Nasal Third Finger (Sharp and Smith, Chi- 
cago) are the best instruments so far devised for this operation. 

A thorough stretching of the eyelids, manipulation of the eye ball 
and the points of the fifth nerve are indicated in many diseases. 

The hds may be stretched by pulling them from side to side. The 
cotted forefinger well oiled (sterile vaseline) may be slipped into the 
conjunctival sac back of either lid and with the thumb on the outside 
the hd may be massaged or stretched in any direction. The points of 
the fifth nerve may readily be infiuenced at their respective exits about 
the orbit. The eye ball and deeper contents of the orbit can be pro- 
foundly treated by pressing the finger into the orbit above, below and at 
the sides of the bulb and pushing it in all directions as far as possible. 
The Ruddy eye finger instrument was devised for this deep manipula- 
tion of the orbital and bulbar structures. It is of high value. One finger 
may be laid on the closed eye and with a tapping motion with the other 
hand a vibration or oscillation of the orbital structures may be had. 
This is a useful treatment. 

The wise selection and skillful use of these various methods of treat- 
ment for the eye will solve most of our difficulties. 

This short survey of osteopathic methods will aid us in the more 
specific discussions to follow. 

Neuralgia 

A convsiderablc number of people seem to be subject to attacks of 
pain in one or both eyes. These attacks of pain come at varying inter- 
vals; in some cases several times a day, in others as far apart as one or 
two weeks. The pain will suddenly start almost without warning and 



198 The Practice of Osteopathy 

with very little provocation, and last from one to twenty-four hours. 
It is very severe and the patient frequently thinks something terrible is 
wrong. Something terrible is wrong so far as his comfort is concerned. 
But in these cases to which I am referring there is no organic trouble with 
the eye. The patient does not need glasses. There is no sign of in- 
flammation. Vision is not disturbed. Local examination of the eye 
with the ophthalmoscope reveals that the fundus of the eye is normal. 
There is no S3anptom connected with the eye except pain, occasionally 
accompanied by a slight redness. I have had several cases in my own 
practice and my attention has been directed to cases of other physicians. 

These cases differ from tic douloureux in that there is no muscular 
spasm. In fact, motor nerves do not seem to be involved. The involve- 
ment seems to be largely in the fifth cranial nerve, usually the supra- 
orbital, or other smaller branches of the ophthalmic division of the fifth 
cranial. Sometimes we note shght dilatation of the pupil with more or 
less congestion. This would indicate an involvement of the sympa- 
thetic branch to the eye. 

The lesions discovered in these cases have been a subluxation of the 
occiput upon the atlas or an upper cervical lesion and frequently some 
involvement at the second dorsal. There has been noted also trouble 
in the nasopharynx such as contractures of the muscles of the soft pal- 
ate and adhesions in the fossa of Rosenmuller. 

Misplacements of the uterus have also been found in some cases. 

Treatment 

Nearly all these cases are curable with from one week to six weeks 
treatment. Of course the treatment must be inteUigently directed 
after a correct diagnosis as to the cause. The cause can usually be re- 
moved. One case to which my attention has been directed was that of 
a woman about forty years of age who had very severe pains. With 
all the local treatment of the eye and otherwise she got practically 
no results until she had replacement of the uterus, which brought immed- 
iate relief. Other cases have no trouble on that kind but have lesions of 
the cervical region and on correction of these lesions the neuralgia dis- 
appears. Other cases have had the nasopharynx cleaned out by the 
finger operation and this stretching of the soft palate which relieved the 
neuralgia immediately or in a few days. Numbers of cases have been to 
medical physicians and had various eye remedies administered locally 
with no permanent benefit. Of course the treatment was administered 
at the wrong place. 



The Practice of Osteopathy 199 

The ramifications of the sympathetic and fifth cranial nerves are so 
complex and far-reaching that we must keep in mind that one or more 
of many causes for the trouble may exist and be quite remote from the 
seat of the pain. 

Diseases of the Eyelids 

Occasional factors are bee stings or insect bites, which completely 
occlude the palpebral fissure. We may have some palpebral edema from 
Hd abscesses, chalazion, hordeolum, dacryocystitis, panophthalmia and 
so forth. In hemorrhagia subdermalis there is so much spongy tissue 
beneath the skin about the eye that the blood extends easily and far. 
The red tint will soon change to a reddish blue and then become dark, 
what is known as a black eye (ecchymosis). This frequently results 
from a blow. The skin is sharply attached around the orbital margin 
by tense connective tissue so the area of the hemorrhage is limited to 
the region of the orbit. There may be spontaneous rupture of some of 
the vessels by hard sneezing or coughing, especially in young children. 
In older people it may indicate a fragile condition of the vessels, arterio- 
sclerosis or some trouble with the kidneys. The diagnosis of the eye 
condition is not difficult but the cause of the hemorrhage in that region 
might be investigated further. Local treatment is of some value in these 
conditions. They may be soothed by cold compresses. In bee stings 
and insect bites use an alkahne compress. Manipulation about the 
eye and osteopathic treatment of the neck with a view to directing a 
better circulation to that region will aid much. 

Herpes Zoster Ophthalmia 

This affection of the supraorbital branch of the fifth cranial nerve 
may extend to the eyelids. It may not go beyond the stage of blistering 
and redness with some edema. However, it is possible for it to become 
gangrenous and even extend to the conjunctiva and cornea. I had one 
case of herpes zoster gangrenosa of this region. There were several 
gangrenous spots as large as a dime on the forehead and extending down 
in the region of the eyelid. The process extended to some extent on the 
cornea and in heahng left a condition of irregular astigmatism. 

Treatment. — The prognosis in herpes zoster is always favorable 
under osteopathic treatment. Lesions of the cervical region will almost 
invariably be found interfering with the sympathetic connections of 
the fifth cranial nerve causing the trophic disturbance to the region. 
Osteopathic treatment applied to these conditions will always hasten 
normahzation. The affected part might be kept covered with some sooth- 
ing lotion to keep the skin soft. 



200 The Practice of Osteopathy 



Hordeolum 



This is commonly known as a sty. It is due to suppuration of the 
glands of Zeiss. It is a harmless affection but causes pain and in- 
convenience. 

Diagnosis. — Swelling and pain with a small inflammed nodule in 
the palpebral margin is quite diagnostic. 

Treatment. — The circulation is obstructed in this region. The 
effort should be made to open the circulation before pus has formed. 
This can frequently be done and the hordeolum aborted by carefully 
picking up the eyelid and rolling the nodule between the fingers. This 
will cause some pain but if it is kept up for a moment or two about every 
hour through the day with an occasional thorough treatment of the neek 
the sty will usually be aborted. If pus forms it should be opened as 
soon as it points and then the squeezing and rolhng process may be em- 
ployed again, wliich will aid rapidly in the freeing of the circulation. 

Chalazion 

This is a Meibomian cyst in the eyelid. It shows as a circum- 
scribed swelling on the inner side of the hd. It frequently becomes 
large enough to produce some deformity of the lid. A chalazion is mov- 
able on the tarsal cartilage. It is a chronic condition and the cyst may 
become as large as a bean. There may be more than one in the same 
lid. 

Treatment. — When a chalazion is small and not of long standing 
it can frequently be cured by osteopathic treatment. Introduce the 
finger into the conjunctival sac under the Hd, and with the thumb ex- 
ternally, grasp the chalazion between the finger and thumb; roll it thor- 
oughly. Squeeze and massage it two or three times a week for awhile. 
This, combined with a thorough treatment of the neck, will result in a 
cure. If at the end of six weeks the condition has not disappeared sur- 
gery should be resorted to. 

Blepharitis 

This is an inflammation of the eyehd. It is either acute or chronic 
according to the cause. Acute blepharitis may be due to heat or injury. 
Chronic blepharitis affects the glands of the lid causing a perversion of 
the secretions. There is usually the formation of crusts and scales. 
This, condition is known as blepharitis sicca. In some cases infection 
will form httle pustules at the roots of the ciha. There is soreness and 
aching. There may be photophobia. The nasal region may be in- 



The Peactice of Osteopathy 201 

volved. Osseous lesions of the cervical region are usually present. Re- 
fractive errors frequently exist in these cases. Occupation or envir- 
onment may expose to dust or wind sufficient to keep up the irritation. 
Treatment. — Change environment. See that there is thorough 
cleanliness of the hd. Rub or pick away all scales. Use a bland oint- 
ment. Correct any cervical or upper dorsal lesions. 

Ptosis 

This is congenital or acquired. In congenital ptosis operation 
seems to be the only treatment. Acquired ptosis is amenable to treat- 
ment frequently. The cause is some lesion interfering with the passage 
of proper nerve force to the levator muscle of the hd. The lesion may be 
at the origin of the third nerve, at the cortical nucleus in the sigmoid 
gyrus or in the trunk of the third nerve, or a lesion of the muscle itself. 
Tumor, trauma, syphihs, sclerosis, hemorrhage, gout or rheumatism, or 
anything that will produce a peripheral neuritis are causative factors. 
Lesions of the cervical and upper dorsal by reflecting back upon the nerve 
centers may produce a ptosis. 

Treatment.— Remedial measures according to indications. Cases 
due to osteopathic lesions as indicated will usually yield readily to treat- 
ment. Where there are other factors treatment must be varied accord- 
ingly. 

Trichiasis 

This is a condition in which part or all of the eye lashes turn in- 
ward and touch the eye ball, due to cicatricial contractions in the con- 
junctiva and tarsus. Many of the ciha are so small in these conditions 
that it is very difficult to see them. A loupe or a magnifying glass must 
be used in order to discover them. 

Dystrichiasis is a condition where the ciha come in irregularly 
growing in all directions, some of them turning in toward the eye ball 
and causing irritation. 

Treatment. — Anepilatory should be used to extract all of the wild 
hairs. Care should be taken to get out the finest ones as they will fre- 
quently cause irritation if not removed. 

Entropion and Ectropion 

Entropion is a turning in of the eyelid and ectropion is a turning 
out. These conditions may be spasmodic and temporary. Entropion 
is more often due to cicatricial contraction in old blepharitis or trachoma 
conditions. In some cases the condition may be corrected by the use of 



202 The Practice of Osteopathy 

strips of adhesive plaster. In cicatricial conditions operation is the rule. 
Spasmodic ectropion may be corrected sometimes by curing the con- 
junctivitis. Bandaging may be resorted to. In paralytic ectropion os- 
teopathic treatment may serve to produce a complete cm*e. Operative 
procedm-e should he a last resort. 

Diseases of the Lachrymal Apparatus 
Dacryocystitis 

Dacryocystitis is an inflammation of the .lacrj^inal sac. It is due 
to some lesion in the nose, malposition of the inferior turbinate or a poor 
blood and nerve supply to the lacrymal region as determined by cervical 
lesions. The sac becomes infected and we have a dacryocystoblen- 
norrhea. Pus and tears are regurgitated into the eye through the 
puncta. There is irritation and the conjunctiva may become infected 
at any time, also the cornea. It is a dangerous and annoying affection. 

Treatment. — Osteopathic measures have something to offer along 
this line. The medical idea seems to be completely surgical in recent 
years. The first and only thing to be done surgically is to obhterate the 
sac or dissect it out and currette the nasal duct, completely destroying 
the apparatus. Lancing does not affect a cure. By treating for a good 
nerve and blood supply to that region, the irrigation of the nose and a 
thorough squeezing of the sac each time with a view to forcing the solu- 
tion in the sac down through the nasal duct into the nose, a cure may be 
effected in many cases. If these cases can be gotten before infection 
has taken place, in the state of epiphora or the backing up of the tears 
into the eye, thorough treatment along the lines just indicated will in 
nearl}^ all cases result in a cure. 

Boric acid solution should be used to wash out the sac when pus is 
present. The attempt should be made to force it into the nose. Prob- 
ing properly done is of value in many cases. These cases should be 
followed up with great care. 

Treat the neck thoroughly and spring the inferior maxilla. 

Diseases of the Conjunctiva 
Conjunctivitis 

The conjunctiva is a mucous membrane that coats the posterior 
surface of the eyelids and the anterior surface of the eye-ball. It forms 
a sac, which is slit open in front in the Une of the palpebral fissure. 

The conjunctiva consists of three parts (1) the conjunctiva tarsi, 
the part on the hds; (2) the conjunctiva bulbi, the part on the eyeball, 



The Practice of Osteopathy 203 

and (3) the conjunctiva fornicis, the part connecting the first and sec- 
ond ; it is the retrotarsal fold or the region of transition, often called the 
fornix. The first part can be seen by everting the lids. It is adherent 
to the tarsus. It is covered with a laminated cylindrical epithelium. 
The membrane contains an abundance of lymphocytes similar to ade- 
noid tissue. This increases with every inflammation of the conjunctiva. 
This is why chronic conjusactivitis often results in thickened lids. 

The blood supply of the conjunctiva of the lids is from the muscu- 
lar branches of the ophthalmic artery. The nerve supply is from the 
ophthalmic division of the 5th cranial and the sympathetic. 

The bulbar conjunctiva continues over the cornea. It is covered 
with layers of pavement epithehum. Its blood supply comes from the 
posterior conjunctival vessels about the retrotarsal fold, and the anterior 
cihary arteries which accompany the tendons of recti muscles; these two 
systems anastomose in the conjunctiva. Conjunctival injection or con- 
gestion shows a superficial net work of larger or smaller vessels that move 
with the conjunctiva. The color is scarlet or brick red. Ciliary injec- 
tion occurs as a rose red or pale violet zone around the cornea, spoken of 
as peri- or circum-corneal injection. It does not move with the con- 
juctiva and occurs more with diseases of the cornea, iris and cihary body. 

In the etiology of conjunctivitis a great variety of germs are con- 
sidered by different writers. CoUins and Mayo give a report of "germs 
found in normal conjunctiva. " 

Bacillus Xerosus in 94% of normal conjunctivae ; Staphylococcus 
Albus in 79%; Pneumococcus in 9%; Diplobacillus in 6%; Staphylo- 
coccus Aureus in 6%; Streptococcus in 5%. 

If this be true, and I do not doubt their statement, we are prac- 
tically compelled to say that these germs at least are only secondary in 
the etiology of conjunctivitis. Just at this point osteopathy comes with 
its flood of Ught and makes it easily explainable why some conjunctivae 
become inflamed while others do not, when all have germs present. The 
lesion disturbing the integrity of blood supply and nerve force to the eye 
is the primary cause while the presence of germs may be the aggravating 
cause. The lesion prepares the soil in which the germs thrive sufficiently 
to become an irritant. There are aU gradations of this soil preparation. 
The more fertile the field (i. e. the more profound the effect of the lesion) 
the more virulent germ life may become; the resistance is proportion- 
ately less. 

Conjunctivitis is classifiecl for convenience in study, diagnosis 
and treatment as follows: 



204 The Practice of Osteopathy 

(1) Catarrhal, (a) acute, (b) chronic, (c) folUcular; (2) gonorrhoeal; 
(3) ophthaknia neonatorum; (4) trachoma; (5) diphtheritic; (6) eczema- 
tosa (phlyctenulosa) ; (7) vernahs; (8) tubercular; (9) traumatic. This 
is the clinical classification after Fuch. 

Treatment of Conjunctivitis 

In order to give the best care in these cases it is quite essential that 
both the primary and secondary causes be given attention. Some good 
germicide or antiseptic is to be used with intelligence. This is in 
harmon}^ with the great principles of antisepsis and cleanliness taught by 
osteopathy from its inception. The use of the microscope in the bac- 
teriology of conjunctivitis aids in more definite diagnosis and the selec- 
tion of a proper germicide. For the Koch-Weeks bacillus, the pneumo- 
coccus and the influenza bacillus silver nitrate 1% or a 25% solution of 
argyrol is used; for the diplo bacillus (Morax-Axenfeld) zinc sulphate 1 
gr. to the ounce is ahnost a specific. 

A good way to prepare the zinc prescription would be : 
Boracic acid and water oz. 1. 
Zinc sulphate gr. 1. 

The boric acid and water of course being a saturated solution. Apply 
one drop to each eye about four times a day. If one can not have the use 
of the microscope to make specific the diagnosis, the zinc solution may be 
alternated with the argyrol as the germicide. Ice cold applications 
are good in many of these cases. 

Catarrhal Conjunctivitis 

Acute — mostly affects the conjunctiva of the lids in the Ught form. 
If severe it invades the bulbar conjunctiva. There is redness and swell- 
ing and increased secretion which dries at night upon the edges of the 
lids and glues them together. The eyes are better in the morning and 
worse toward evening. Corneal ulcers and iritis may arise as compli- 
cations. Chronic inflammation may result. 

Etiology. — Textbooks on the eye give bacteria as the chief cause; 
some scarcely mention anything else. After discussing how the bacteria 
get there and multiply, they usually bring in some statement to indicate 
that in many cases no bacteria can be found in the secretions from the 
conjunctiva. These latter are unaccounted for in the etiolog3^ 

Catarrhal conjunctivitis is non-specific in its origin. 

The great science of osteopathy will fill in the missing Unks to works 
otherwise very exhaustive on the eye. 



The Practice of Osteopathy 205 

If the cause is due only to a passing irritant as dust, smoke, pollen 
or wind the disturbance may vary from hyperemia only, to a severe attack 
of conjunctivitis. Fuch says the majority of cases are produced by bac- 
teria, but THAT IN NOT A FEW CASES OF CONJUNCTIVAL CATARRH THE 
EXAMINATION OF THE SECRETIONS FOR BACTERIA PROVES NEGATIVE. He 

also says that the usual course of the disease is from eight to fourteen 
days, but not infrequently there remains a condition of chronic 

CATARRH PROTRACTED OVER A LONG TIME ; THAT NOT INFREQUENTLY THE 
NORMAL CONJUNCTIVAL SAC CONTAINS PATHOGENIC GERMS. 

Some authors divide the etiology into (1) specific, (2) non-specific. 
The first they account for by irritants due to dust, heat, smoke, metal, 
pollen, cold, wind, glare of Kght, eye-strain from overwork of the eyes, 
ametropia and chronic alcohohsm. The second they account for by 
germ life, most often the Morax-Axenfeld diplobacillus or the Koch- 
Weeks bacillus, the latter germ being found in the so-called ''pink-eye." 
It is contagious. This is one condition for which the zinc sulphate (^% 
to 2% solution) is almost a specific. 

No doubt the irritants and the bacteria mentioned, with others, do 
cause much of our catarrhal conjunctivitis and that one who fails to 
consider properly the local conditions in practice wiU be sadly lacking in 
best results. 

On the other hand many cases, treated for local conditions only by 
very competent men who used the best antiseptics and germicides, have 
very indifferent results. The acute condition would continue and grad- 
ually become chronic. From observation, study and experience there 
are causes aside from local irritants, ametropia, bacteria, syphihs, rheuma- 
tism or measles. There is some disturbance to the integrity of the spino- 
ciliary sympathetic arc. In many cases of eye disease note lesion and 
tenderness at the upper dorsal, the removal of which will cause improve- 
ment of the eyes. Many cases of eye strain can be relieved by correction 
of the first, second or third dorsal, and the use of glasses made unnecessary. 

Irritation of the eye wiU cause more or less tension of the muscles 
at the second and third dorsal, and stimulation of the tissues near the 
second and third dorsal spines will cause dilatation of the pupils and 
contraction of vessels of the cranial mucous membranes; which means 
vasomotor, secretory and trophic disturl^ances. 

It follows then that an osteopathic lesion at the second or third 
dorsal will cause or tend to cause disease of the eye. There may be all 
gradations in the effect produced, the lighter being mere tendency, while 
again it may be enough to set up profound vasomotor, secretory and 



206 The Practice of Osteopathy 

trophic changes in and about the eye. The first effect of the lesion may 
be stimulatory, and later, inhibitory. The normal resistance of the eye 
would be lowered and naturally, local irritants, bacteria and ametropia 
would have a more profound effect. This will explain how one can devel- 
op conjunctivitis in the absence of a local irritant with no bacteria pres- 
ent, and no eye strain. 

All of these causes, or any number of them, may be acting together, 
and each more virulent because of the influence of the other. 

Lesions of the occipito-atlantal joint or any of the cervical ar- 
ticulations may cause eye disturbance. There are no efferent rami-com- 
municantes in that region and the course of the physical disturbance 
must be greater in proportion to the eye trouble produced, than at the 
upper dorsal. It is important however to make a close examination of 
the entire cervical region in eye trouble. 

What has been said on the osteopathic causes of acute catarrhal 
conjunctivitis applies with equal force to chronic and follicular con- 
catarrhal conjunctivitis. 

What has been said on the osteopathic causes of acute catarrhal 
conjunctivitis apphes with even greater force to the chronic from. The 
great variety of local irritants may account for acute conjunctivitis, and 
does in most instances; but in chronic conjunctivitis local irritants are 
more often secondary or incidental while the osteopathic lesion with its 
effect upon the bulbo-spino-sympathetic ciliary arc is the funda- 
mental cause. Of course some continuous local irritant, e. g., an un- 
corrected refractive error, excessive Hght, heat, dust or germ Hfe in the 
environment may cause a chronic conjunctivitis. Other causes may be 
retracted hds (lagophthalmus) leaving the eyeballs too prominently ex- 
posed; turning in of the ciUa (entropion, trichiasis or dystrichiasis) which 
impinge upon and irritate the bulbar conjimctiva. Chronic blephar- 
itis may spread to the palpebral conjunctiva and then the bulbar. For- 
eign bodies in the eye, or infarction of Meibomian glands may be causes. 
The diplobacillus (Morax-Axenfeld) is the most common germ in chronic 
catarrhal conjunctivitis. 

Symptoms and Course. — In mild cases the redness is only mod- 
erate. The conjunctiva is smooth and not swollen. Old cases have 
hypertrophy with thickening. There was a small girl who came into the 
office recently who had the conjunctiva of the hds decidedly swollen with 
some hypertrophy. Her eyes were glued shut with pus every morn- 
ing. Pus pockets were forming along the folhcles of the cilia and on the 
direct edge of the fid. Her troubles started a year ago and got gradually 



The Practice of Osteopathy 207 

worse. A few osteopathic treatments were given during three months 
(she was irregular in coming) and argyrol, 20%, used locally. All pus 
and debris were cleared off the lids and conjunctiva each time. The 
swelling all left and the thickening became inconsiderable; the eyes looked 
almost clear. On pressure there was tenderness at the right side of the 
second dorsal. No mechanical lesion was apparent there but in treat- 
ment that region was thoroughly loosened. 

The subjective symptoms are usually worse at night; pain, heavi- 
ness of the lids; feeling of a foreign body in the eye; burning; itching and 
dryness in many cases. 

This condition is one of the most frequent of eye diseases in adults; 
may be senile catarrh in advanced age. It is frequently complicated 
with blepharitis, ectropion, epiphora and ulcerations of the cornea. 

Treatment. — The osteopathic treatment depends on the findings 
in the osteopathic examination. No case of chronic catarrhal conjunc- 
tivitis should be treated without a thorough examination of the whole 
spinal, rib and innominate mechanism. Careful and detailed adjustment 
should be made of any lesions that might disturb the ciHary arc, the 
other nerve connections, the blood supply or the body equiHbrium. 

This does not mean that local treatment of the eye should be neg- 
lected in any way. Any measure that will aid in getting rid of local 
pathology as quickly as possible should be ours. Where there is abun- 
dant secretion, silver nitrate 1% to 2% solution put on the conjunctiva 
with a brush when the lids are turned, or argyrol 20% to 25% dropped 
into the eye are among the best antiseptics for local use. If the diplo- 
bacillus is present zinc sulphate |% solution is indicated. 

The nose, nasopharynx and pharynx should never be overlooked in 
this disease. 

Follicular Conjunctivitis 

Follicular conjunctivitis is of catarrhal origin. It is charac- 
terized by the presence of follicles. There may be only a few or a great 
many. If numerous they are often in rows on the palpebral conjunc- 
tiva. Microscopically they show as circumscribed masses of adenoid 
tissue. In this they resemble the granules of trachoma. Sometimes 
cases persist for years with little or no inflammatory symptoms. On 
account of the follicles this disease is frequently confused with trachoma. 

We have heard numbers of well meaning conscientious osteopathic 
physicians testify to curing cases of trachoma with a short course of 
osteopathic treatment with no pathology remaining. We are absolute 



208 The Practice of Osteopathy 

believers in the effectiveness of osteopathic treatment and want, to give 
it full credit for doing all it will; but here we want to enter a plea to the 
profession that we need more discrimination and definiteness in our diag- 
nosis. Technique is being emphasized and we say Amen! It is proper 
for us to be thoroughly competent in technique but diagnosis should be 
made just as emphatic because scientific technique depends upon diag- 
nosis for each individual case. 

Difierentiation of follicular conjunctivitis from trachoma. 

Follicular conjunctivitis occurs (1) chiefly in the young; (2) 
the folhcles are smaller, more sharply limited, project more above the 
conjunctiva, are often in rows, and oval in shape; (3) the disease clears 
up with no bad after effects often without any treatment and the ten- 
dency is to ultimately get well; (4) it never leads to shrinking of the con- 
junctiva, to pannus or other destructive sequelae ; (5) it can arise without 
contagion and is not considered contagious although, hke trachoma, it 
does attack large numbers of people who are confined in a small place. 

Trachoma. — (1) It seldom occurs in cliildren; (2) the folhcles are 
larger, do not have sharp outlines, are less prominent under the con- 
junctiva, are round in shape and never in rows; (3) tends to lead to more 
or less pathology and seldom recovers spontaneously; (4) scar tissue 
becomes a product of the inflammation in the conjunctiva and leads to 
shrinking of the conjunctiva, causing in turn entropion and trichiasis. 
Pannus is the sure result of unarrested cases as there is a tendency to 
infection of the cornea from the infected conjunctiva moving over it 
and remaining in contact; (5) trachoma has been proved to be contag- 
ious. Trachoma bodies which are considered the infective agent have 
been isolated. 

The use of atropine in some instances will cause a follicular catarrh 
which clears up on stopping the use of the poison. 

Parinauds "Infectious conjunctivitis" has granulations but almost 
always occurs in only one eye and is accompanied with constitutional 
sjmaptoms. 

Treatment of Follicular Conjunctivitis. — The treatment should 
be directed against the inflammation. The trophicity of the nerve 
terminals to the conjunctiva may be altered by osteopathic lesions. 

Suggestions under chronic catarrhal conjunctivitis apply here. If 
there is no inflammation the folhcles tend to disappear, leaving no trace 
of patholog}^, hence a few osteopathic treatments of the Uds and the 
cervical region will hasten normahzation. 



The Peactice of Osteopathy 209 

Gonorrheal Conjunctivitis 

This disease is sometimes called purulent ophthalmia or acute 

blennorrhea. It is caused from an infection of the conjunctival sac 
with the gonococcus of Neisser. Contact with soiled fingers or linen may 
transfer the germ. 

Symptoms. — Within 12-48 hours after inoculation the first symp- 
toms of redness and irritation occur. This is soon followed by much 
swelling and tension of the Hds and chemosis of the conjunctiva. There 
is much pain and a copious discharge of pus coming from beneath the 
lids. At first the pus is yellow or yellowish green. 

Later the symptoms begin to subside; there is less tenseness and 
heat; the lids can be more readily everted and the discharge ceases after 
6 or 8 weeks. The puckered conjunctiva becomes rough and granular. 

In these cases the prognosis is always grave; more so than in oph- 
thalmia neonatorum. The eye is almost always marred in some way. 
One of the great dangers is involvement and destruction of the cornea. 
If the cornea becomes hazy soon after symptoms begin it is not a good 
omen. Ulcers will Hkely form and then there is a tendency to punc- 
ture the cornea. In mild cases the cornea may escape without injury. 
In severe cases it is likely to ulcerate. If it perforates, the anterior 
chamber is emptied and the iris prolapses into the perforation; adhesions 
take place and there is heaHng with reformation partially of the anterior 
chamber. An adherent leukoma is the result with practical loss of vis- 
ion. There may be a bulging of the cornea known as anterior staphyl- 
oma. The iris and ciHary body may become involved, causing iritis 
and cycHtis, or the whole inner structures may be affected making a 
pan-ophthalmitis with atrophy of the eyeball. 

The cornea is affected by the infective material direct or the nutrient 
vessels to the cornea at the limbus may be obstructed by the extreme 
swelling and pressure. 

Complications of arthritis, rhinitis, septicemia and endocarditis 
may arise. If there is none of these, at least there is a general debilitated 
condition which needs attention. 

Treatment. — The treatment should be local and constitutional. 
The diagnosis should be made quickly from the history, symptoms mi- 
croscopically, and local cleansing begun at once and followed diligently. 
Excessive discharge should be wiped away with cotton. The conjunc- 
tival sac should be thoroughly irrigated every hour or oftener if necessary 
to keep it clean. This is to be done day and night. A saturated solu- 



210 The Practice of Osteopathy 

tion of boric acid may be used, or corrosive sublimate one grain to the 
pint, or permanganate of potassium solution 1-5000. The irrigation 
should be followed by the free use of argyrol 25%. This procedure will 
keep the eye clean and be the means often of saving the cornea from de- 
struction and the eye from bhndness. 

If there should be ulceration of the cornea a drop of atropine |% 
should be used in the eye often enough to keep the pupil dilated and 
the ciliary body at rest. 

Osteopathic physicians no less than other physicians should not 
neglect this local, careful, persistent, antiseptic cleansing of the eye in such 
cases. Theosteopathist can do more. He is not limited to antisepsis 
even in this kind of work, however important it might be. The unaf- 
fected eye should be carefully protected. Buller's shield should be used. 

The osteopath should give thorough treatments to the neck and the 
fifth nerve. 

Supporting treatment to the system according to indications should 
be given e. g., bowels, kidneys, nerves, muscles, joints as in constipation, 
nephritis, neurosis, rhemnatism, arthritis, endocarditis, septicemia, 
rhinitis etc. 

Ophthalmia Neonatorum 

This is an acute purulent conjunctivitis in the new born. Neona- 
torum comes from a junction of the Greek word Neos — new, to the Latin 
word natus — born; new-born. This disease is the bugbear to the ob- 
stetrician. He must always be on the lookout for it and act promptly in 
order to save sight. Every general practician should make a careful 
study of this disease if he expects to treat children. 

Sixty to seventy percent of conjunctivitis neonatorum is due to the 
infection with the gonococcus of Neisser. It usually comes from a 
gonorrheal discharge from the genitals of the mother. The nurse or 
anyone who handles the baby might be the agent in the transmission of 
the infection. 

The disease is not always of gonorrheal origin. Some cases are due 
to the pneumococcus, streptococcus, diplobacillus or one variety of staph- 
ylococci. 

Thus there are two varieties or types of ophthalmia neonatorum; a 
severe type which is gonorrheal or specific and a mild type which is non- 
specific. 

In some states there is a law which requires the use of silver ni- 
trate in the eyes of all babies at birth. Every baby's eyes should be 



The Peactice of Osteopathy 211 

thoroughly washed at birth, with boric acid and where there is the least 
suspicion of gonorrhea silver nitrate 1% or argyrol 25% should be used. 
A routine use of one of the silver salts would be good practice. 

Symptoms. — Gonorrheal cases begin usually the third day after 
birth, non-gonorrheal, on the fifth or sixth day. Both eyes are usually 
involved, one worse than the other. The lids swell much. There is 
chemosis of the conjunctiva which may put the cornea in a pit. The dis- 
charge is abundant. It is yellow or greenish yellow. 

The disease gradually declines and the discharge ceases in six to 
eight weeks. The conjunctiva is thickened and looks granular. May 
be some cicatricial changes. 

The chief danger is to the cornea, more so if it becomes hazy the first 
two days. Corneal lesions seldom occur in non-specific forms. 

If the cornea is involved perforation is likely, with a general in- 
flammation of the eyeball (panophthahnitis) followed by atrophy (phthis- 
is bulbi). 

CompHcations such as rhinitis, meningitis, endocarditis and general 
septicemia may occur. 

Diagnosis is made from the onset, character, symptoms and course 
with the use of the microscope. 

Prognosis. — Delayed or improper treatment in these cases will 
likely be fatal to sight as sloughing of the cornea will occur. With 
prompt and proper care the prognosis is favorable. 

Treatment. — Mild cases (non-specific) are treated in the same 
manner as simple conjunctivitis. In severe cases (specific) clean the eye 
carefully and apply cold compresses of gauze 15 to 20 minutes at a time 
every hour or two. Keep the gauze on a block of ice and change every 
few minutes. If the cornea is involved heat may prove more satisfactory. 
There must be constant removal of the discharge. Wipe away the ex- 
cess and irrigate freely with boric acid at least every hour day and night 
and more often if necessary. After each washing use a solution of ar- 
gyrol 25%. Once a day silver nitrate 1% solution may be used and 
washed out with a salt solution. 

If the cornea should ulcerate the treatment need not be altered. 

The attendants should be carefully instructed as to the importance 
of the care and the contagious nature of the pus. 

Antisepsis and cleanhness here is more essential, effective and ex- 
clusive than in any other disease of the eye. Wisdom in the use of anti- 
septics is a strong point in the armamentarium of every progressive os- 
teopath. 



212 The Practice of Osteopathy 

Trachoma 

Tliis disease is known as granular lids or granular conjunctivitis. 

Although the germ has not been discovered, we know this is an infectious 
disease. A roughness and hypertrophy of the conjunctiva develops. 
There is development of follicles or granulations. Later these products 
are absorbed and cicatrization of the tissues follows. 

Cause. — Trachoma is found most common in Egypt and Arabia. 
It spreads easily in crowded institutions. It is in many instances a 
mixed infection with the Morax-Axenfeld bacillus, Koch-Weeks bacillus 
and the gonococcus. 

"Trachoma bodies" have been discovered which are claimed by 
some to be a causative factor in the disease. These small bodies are not 
found in all cases however. 

Spinal lesions of the cervical and upper four thoracic vertebrae will 
disturb the blood and nerve supply to the eye which will predispose to 
the disease should some of the virus or germs of trachoma be present. 
In practically all these cases there is tenderness if not an actual twist 
at the second and third thoracic. 

Symptoms.— A small boy came to our cUnics complaining that his 
left eye was smaller than the right. No inflammation or swelling was 
prominent. The eye looked normal except slightly smaller than the 
right. On turning the Hd granules in the fornix of that eye were readilj^ 
noticed. Trachoma had a good start. The tissues were so hyper- 
trophied in that region that the eye could not be opened quite as wide 
as the other one, hence the impression that that eye-ball was smaller. 
The granulation often develops so insidiously that the victim may have 
the disease for months before he realizes he has a bad eye. When symp- 
toms appear there may be photophobia, lachrymation, gluing of the hds 
from a scanty secretion, pain, and blurring of vision. The granules are 
gray, translucent and roundish under the conjunctiva. 

Hypertrophy increases to a certain height when cicatrization and 
contraction begin. The duration may be years. The more the hyper- 
trophy the longer the duration and the greater the contraction. (Note 
here that treatment should be directed toward combatting the hyper- 
trophy by establishing circulation). 

Sequelae. I merely mention the sequelae here: pannus, ulceration 
of the cornea, trichiasis, dystrichiasis, entropion, ectropion, symble- 
pharon, xerosis, corneal opacities. For the explanation, pathology and 



The Practice of Osteopathy 213 

treatment of these sequelae not covered in this treatise, see any good 
works on diseases of the eye as Weeks, Fuchs or De Schweinitz. 

Treatment of Trachoma. — -In reporting cases of trachoma treated 
and cured by osteopathy we should be sure of our diagnosis. 

The treatment is antiseptic, hydrotherapeutical, osteopathic and 
operative. A saturated solution of boric acid should be used. Argyrol 
20% is good if there is much secretion. Nitrate of silver 2% and copper 
sulphate are still used in some cases to advantage as claimed by some 
physicians. The osteopath should count on careful cleanliness. 

Hot compresses over the eyes are often very agreeable. 

Operations are often performed for trachoma. The granules are 
rolled out with Knapp's roller forceps, and other methods. 

Grattage is practiced with some wonderful results. It is done as 
follows: Get some fine sand paper and cut it in strips about one-half 
inch wide by three or four inches long. Put it in alcohol in a vessel for 
ten to fifteen minutes. Pour off all the alcohol except a few drops that 
will cling to the vessel by capillary attraction. Touch a match to the 
residue. This will burn just enough to make the sand paper absolutely 
sterile without burning the latter. Put the patient under somnoform. 
Use a small artery forceps to grasp the edge of the eyeHd, roll the lid 
back over the artery forceps to expose all granulations clear to the fornix. 
Use a protector to the eyeball. Now with the sandpaper quickly scrape 
or curette away all of the trachoma bodies and granulations. Re- 
peat the process on the other eye if it is involved. Wash out well with a 
saturated solution of boric acid and bandage the eyes for a few hours. 
This will cause considerable swelling and inflammation. Use cold appli- 
cations and keep the eyes disinfected. I have seen some very good re- 
sults from this method. 

Osteopathic. — Following the sand paper operation a thorough 
treatment of the cervical and upper dorsal region would add consider- 
ably to the rapidity of the patient's recovery and sense of well being. 
General tonic treatment is of special benefit in nearly all trachoma cases 
as they are subnormal in their general health. 

One form of technique which has been used by myself and others to 
advantage in these cases is as follows: SteriHze the fingers carefully, 
lubricate with vaseline or K. Y. the forefinger of the right hand. With 
the left hand raise the upper lid and introduce the forefinger of the right 
hand with the thumb above. Catching the lid between the thumb and 
finger squeeze and massage the whole structure clear to the fornix as 
tho]'Oughly as possible. Repeat the process on the other eye. 



214 The Peactice of Osteopathy 

A technique used by Dr. Edwards of St. Louis is as follows: After 
sterilizing and lubricating the forefinger hft the hd and introduce the 
finger as far as possible into the orbit pushing the fornix back into the 
orbit. This stretches all the tissues around the fornix, opening up a 
better conjunctival and palpebral circulation. The ciliary vessels and 
nerves are stretched and stimulated. It is rather surprising to one who 
has not tried it, how far the finger can be introduced into the orbit. 

One set of nerves that should be especially studied and considered 
in trachomatous conditions is the cere-brobulbo-spino-sympathetic-cil- 
iary arc. This has already been elaborated. All spinal lesions should 
be carefully diagnosed and corrected. 

Dr. T. J. Rudd3''s third finger eye instrument is very useful in these 
conditions in restoring normal circulation about the orbit. 

See that the nose and throat are normal. 

Phlyctenular Conjunctivitis 

By some this disease is considered an eczema of the conjunctiva. 
This will at least enable us to get an idea of the conjunctival pathology. 
What is said of phlyctenular conjunctivitis applies largely to its cor- 
responding disease of the cornea-phlyctenular l<eratitis. Scrofulous 
ophthalmia is applied by some because so many of these phlyctenular 
patients have scrofula. Herpes conjunctivae is used as a name because 
of the small bMsters or blebs that form in the beginning stage. Little 
red eminences develop near the hmbus (sclerocorneal junction). They 
are cone shaped, shghtly elevated about the surrounding tissue. There 
may be one or several, usually not more than one or two. After a few 
days the cone breaks and on top appears a small gray ulcer. There is 
further breaking down and the cone disappears leaving an ulcer on level 
w4th the conjunctiva. Vessels are congested about it. There may often 
be noted an area of small vessels, fan like in shape, running from the outer 
region of the conjunctiva to the ulcer or phlyctenule. 

Etiology. — This is a disease of frequent occurrence in children, 
mostly among the poor classes. Such things as eczema, dirt, adenoids, 
scrofula, rhinitis, malnutrition, abuse of tea and coffee and exanthematous 
disease are mentioned by ocuKsts as causes. I have no doubt any or all 
these conditions predispose to phlyctenular conjunctivitis. 

De Schweinitz in "Diseases of the Eye," 1916 edition, p. 242, says: 
"The exact cause of ocular lesions, or phlycentular eruption, has not 
been determined. " 



The Practice of Osteopathy 215 

I have met Dr. De Schweinitz and heard him lecture on the eye. 
I consider him one of the best eye speciahsts in the country. His ex- 
perience and study with the eye dates over many years and his book has 
gone through eight editions. He is professor of ophthahnology in the 
University of Pennsylvania; Ophthalmic Surgeon to the Philadelphia 
PolycHnic Hospital, the Philadelphia General Hospital etc., etc. 

His opinion represents the summary of the investigation of the oph- 
thalmic profession the world over and through all the past down to the 
present time. "The cause of phlyctenular conjunctivitis is not known. " 

Bacteriology. — At times in the ulcers have been found the staphy- 
lococcus pyogenes aureus and albus. They are also found in a normal 
conjunctival sac. They could not with logic be taken as a causative 
factor; at least they would be only secondary. 

If oculists and other students of the eye all had a good deep osteo- 
pathic vision to throw hght upon these problems many causative factors 
would take on a new meaning. Such supposed causes as have been men- 
tioned, e. g. eczema, adenoids, rhinitis and malnutrition may easily be 
secondar}^ to the osteopathic lesions. Micro-organisms may be enabled 
to act because of trophic and circulatory disturbances to the conjunc- 
tiva through disturbed nerve connections from lesions in the cervical and 
upper dorsal regions. Herpes zoster is purely a trophic nerve disturb- 
ance manifestation on the skin as blebs or bhsters with more or less 
neuritis. Any lesion that would affect the integrity of the function of the 
fifth cranial nerve might easily manifest itself as herpes of the conjunc- 
tiva. 

We beHeve the osteopathic lesion is primary and fundamental in the 
causation of most of our phlyctenular conjunctivitis. Of course insani- 
tation, scrofulous diathesis and the exanthemata play their roll. A 
good diagnostician should figure out the relative importance. The his- 
tory, onset and examination will usually ehminate these conditions. 

Symptoms. — Lachrymation, photophobia, blepharospasm and in- 
jected vessels are the chief symptoms. There is pain as well as fear of 
light. The child fights examination. 

The attack subsides in ten to fourteen days unless there is multi- 
phcity of blebs. Some patients have repeated attacks for months or 
years. Many of these cases in medical clinics keep coming for months 
with repeated attacks. Never leave out careful osteopathic treatment. 

Prognosis. — This is favorable for a final cure. If there should be 
multiple ])lebs and frequent recurrence and the cornea is invaded, the 
prognosis is not good for perfect sight. The pathology goes deep enough 



216 The Practice of Osteopathy 

to affect Bowman's membrane of the cornea disturbing the substantia 
propria. This causes a macular condition of the cornea which impairs 
sight. 

Therapy. — Diet should be bland; the eyes should be protected 
from irritants; yellow oxide ointment should be used in the eye once a 
day or 10% argyrol. The ointment is preferred. Moist warm com- 
presses on the eye are comforting. A boric acid wash in almost all conjunc- 
tival trouble is good. If there is much irritation giving a suspicion of 
iris involvement a drop of atropine |% should be used. The general 
regimes of Uving should be regulated. 

Osteopathic treatment should be directed toward building up the 
general health and correcting all lesions, especially that may have a spe- 
cific bearing on the eye trouble. Such lesions will be found more often 
at the first, second and third thoracic, but may be anywhere from there 
to the occiput. 

Vernal Conjunctivitis 

This disease is known by many as vernal catarrh or spring ca- 
tarrh of the conjunctiva. It is a chronic inflammation which sets up 
changes in the conjunctiva and tarsus. This disease may be confused 
with trachoma unless one observes closely. There are broad flat papil- 
lae on the conjunctiva. These papillae may readily be taken for granula- 
tions. They are larger than the granules in trachoma. They somewhat 
resemble the arrangement of cobble stones. The conjunctiva has a 
bluish- white filmy appearance called by some, milky shimmer. 

The disease was thought at first to appear only in the spring, hence 
the name vernal. Many cases continue through the year with exacerba- 
tions in the spring. It occurs more often in boys. Both eyes are at- 
tacked. It may heal and leave no trace. It may last from four to 
twenty years. 

Causes. — Almost all works on the eye say the cause is not known. 
De Schweinitz says, "Definite information in regard to the cause of this 
disease is lacking." There may be a micro-organism which has not 
been discovered. 

I wish to call the attention of the osteopathic profession to the great 
fact that there are numbers of diseases of the eye as well as of other parts 
of the body about which the medical profession are entirely "at sea." 
This gives valualjle ground for scientific research by our profession. 

My experience with this disease is not sufficient for me to speak with 
any positivencss or finality as to its cause. The altered trophic parts 



The Practice of Osteopathy 217 

and the very chronic condition existing leads me to the firm belief that 
we will ultimately find the "cause as a mechanical lesion affecting the tri- 
geminal or sympathetic (or both) nerve connections. Glare of Hght 
and local irritants act only as secondary causes. Nasal disease may be 
associated and act as a cause. 

Symptoms. — There is photophobia, some mucus, slight pericor- 
neal injection, redness of the conjunctiva of both the bulb and Hds; that 
of the hds is thickened and of dull pale color due to sub-epithehal hya- 
line thickening. The fact that there is no pannus, and flat granulations 
and recurrence with spring, marks it from trachoma. 

Prognosis. — Under medical treatment it is unfavorable; may last 
twenty years. Shght opacity of the cornea may develop. 

Treatment. — The eyes should be protected with dark glasses. Cold 
compresses give some relief. Boric acid is good as a wash. Yellow 
oxide of mercury ointment may be of service as an antiseptic and alterna- 
tive. If nasal disease exists, it, of course, should be treated according 
to indications. Fundamentally the lesions in the spine in the cervical 
and upper dorsal regions should be specifically corrected. When enough 
cases of vernal catarrh have been observed and treated osteopathically 
much hght and benefit will be brought to bear upon this obscure and in- 
tractable disease of the conjunctiva. 

Diseases of the Cornea 
Anatomy 

The cornea with the sclera forms the outer coat or tunic of the eye 
ball. The cornea is in front and forms one-sixth of the envelope. It is 
a segment of a smaller globe than that of the sclera. It is about 12 
mm. horizontally and 11 mm. in the vertical diameter. Its thickest 
part is at its junction with the sclera where it is about 1 mm. This 
junction is caUed the limbus. The cornea is inserted into and rests on 
the sclera Hke a watch crystal. The fibers of the cornea pass continu- 
ously into the sclera, however. The normal cornea is transparent. 
Most morbid changes of the cornea cause a diminution in tliis trans- 
parency. In old age a narrow gray line near the corneal margin makes 
its appearance. This is known as the arcus senilis. There is a little 
strip of perfectly clear cornea between the arcus senilis and the limbus. 

The cornea has five layers. These layers should be noted with 
care, as in wounds of the eye, foreign bodies in the cornea and ulcerations, 
the results depend much upon which layers are affected. 



218 The Practice of Osteopathy 

1. The anterior epithelium consists of pavement cells of several 
layers. This layer of the cornea may be damaged or scratched off in 
large patches and still it will heal readily leaving no trace of the injury. 

2. The anterior elastic lamina or Bowman's membrane is 

very thin and homogeneous; it is just beneath the epithelial layer and 
forms a resisting sheath to prevent damage to the next layer. 

3. The stroma or substantia propria. This layer composes 
about nine-tenths of the cornea. It is composed of minute connective 
tissue fibers between which he some stroma cells or corneal corpuscles. 
Some of these cells are fixed while others are motile. The motile ones 
are the white blood corpuscles wliich move about in the lymph passages 
of the stroma. They increase in any irritation of the cornea. 

4. Descemet's membrane. This is a tough homogeneous hyaloid 
membrane back of the stroma. When the stroma is diseased and breaks 
down Descemet's membrane may be sufficient to prevent a puncture of 
the cornea. 

5. The Endothelial layer is a single layer of flattened cells which 
coat the posterior surface of Descemet's membrane. 

The margin of the cornea is in relation with three membranes, the 
conjunctiva, the sclera and the uvea (iris and ciliary body). In a dis- 
ease of the cornea, a conjunctivitis, an iritis or a cychtis is easily started. 

The cornea contains no vessels. It is nourished by imbibition. At 
the hmbus there is a rich network of marginal loops suppUed by the an- 
terior cihary vessels. From these loops the blood plasma passes into the 
stroma of the cornea. 

The nerves of the cornea come from the cihary nerves and the nerves 
of the bulbar conjunctiva. These are from the trigeminus and the sym- 
pathetic. The nerves extend numerously in the stroma passing for- 
ward through Bowman's membrane into the epitheUal layer. This 
makes the cornea very sensitive to the touch. 

Examination of the Cornea 

Note the size and form. Both may be modified by morbid processes. 
Note the surface with regard to curvature, evenness and smoothness. 
In keratoconus the curvature is greatly increased. Noting the reflex 
images in the cornea and comparing these with those of a normal cornea 
will show any variation in curvature. Also any unevenness of the 
surface may be noted by the irregularity or distortion of the images. 
Uneven spots on the cornea may be depressions or elevations from 
loss of substance; wrinkles or collapse from lowered tension. 



The Practice of Osteopathy 219 

If the smoothness or polish of the cornea is lost it looks like glass 
that has been breathed upon or greased. It is lusterless and dull. 

Note also the transparency of the cornea and determine the form, 
extent and density of the opacity; whether it is diffuse or in spots; in the 
deep or superficial layers. A magnifying glass should be used in the 
study of opacities. According to the density of the opacity of the cornea 
it is known as a nebula or a nebulous opacity, a macula or a leu- 
coma. The nebula is the least noticeable and the leucoma is the dens- 
est opacity. A leucoma is a condition of complete opacity. The cornea 
looks white. 

Defects in the corneal epithelium may be made to show clearly by 
the use of a 2% solution of fluorescein which stains them green. 

Note the sensitiveness of the cornea by touching it with the end of a 
thread, a Little cotton or a shred of paper. The sensitiveness is diminished 
or lost in glaucoma and some other diseases. 

Diseases of the Cornea 

Almost all diseases of the cornea have some form or degree of inflam- 
mation. Keratitis is the word generally used for inflammation of the 
cornea. In order to aid clearness in discussion there are various sub- 
divisions of keratitis made by different writers. Suppurative and non- 
suppurative are the principal types. In suppurative keratitis there 
is always some destruction of corneal tissue which on healing leaves an 
opacity with partial loss of vision. Germs gain entrance into the tissues 
usually from the exterior and some form of ulceration results. 

The following classification is taken from Fuchs: 

Suppurative Keratitis. — (1) Ulcer of the cornea; (2) Serpiginous 
ulcer; (3) Keratomalacia or Xerosis; (4) Keratitis neuroparalytica. 

Non-suppurative Keratitis. — (A) SuPERFiciAii: (1) Pannus, 
or keratitis with blood vessels; (2) Phlyctenular, or keratitis with ves- 
icles. (B) Deep: (1) Parenchymatous or interstitial. 

In keratitis there is first an infiltration or the increase of cells in 
the substantia propria or the parenchyma of the cornea. This is the 
exudate of the inflammation. It causes the cornea to look more or less 
dull or cloudy. The disease may clear up at this point or go on to sup- 
puration. If it clears up it is known as resorption. If the lamellae 
of the substantia propria are not destroyed by the process, resorption 
takes place with no loss of substance. The exudate disappears and there 
is perfect transparency of the cornea again. There may be sUght dam- 
age of the stroma preventing perfect transparency. Resorption of the 



220 The Practice of Osteopathy 

exudate may not be quite complete which may become partly organized 
and left permanently fixed in the cornea. Cases resorbing without 
destruction of the stroma are forms of the non-suppurative keratitis 
group. 

If the stroma breaks, suppuration occurs. This is the second stage 
and is associated with a localized destruction of the cornea. These cases 
are known as suppurative keratitis or ulceration of the cornea. 
The disintegration begins in the most anterior layers of the cornea. A 
sHght depression in the cornea can be noticed. The infiltration is all 
about the ulcer, getting less as it is more remote from it. If the floor 
and walls of the ulcer are foul with the infiltrate it is known as a pro- 
gressive ulcer. Sloughing may continue to spread the ulcer. 

If the cloudiness around it disappears and the ulcer acquires a smooth 
transparent base and edges it is known as a retrogressive or clean ulcer. 

The disintegrated areas of the cornea may be replaced by newly form- 
ed tissue. This is the tliird stage or that of cicatrization. This new 
tissue is connective tissue. It is opaque, leaving a permanent opacity. 

Stages of Iceratitis: 

Suppurative — (1) Infiltration; (2) Suppuration and (3) Cicatriz- 
ation or Reparation. The suppuration is progressive or retrogressive. 

Non-suppurative — (1) Infiltration; (2) Resorption. 

In the diagnosis of a keratitis one should look at it very carefully. 
A loupe which has tliick plus sphere lenses will magnify the field and may 
be of great assistance in observing closely the condition. 

If the cornea is clouded and dull the trouble is recent and if there is 
no loss of substance it is an infiltrate (first stage). If there is loss of 
substance it is a progressive ulcer (second sage.) 

If the surface is lustrous but cloudy the trouble is an old one and if 
there is loss of substance it is a retrogressive ulcer; if no loss of substance it 
is a cicatrix. 

Frequently blood vessels grow in from the margin in ulcerations of 
the cornea. This is usually a process of healing of the corneal ulcer. 
The advent of the blood vessels is favorable. After heahng the blood 
vessels gradually disappear. They never entirely disappear from large 
cicatrices. 

In some cases new vessels accompany the inflammatory process and 
like the exudate are a part of the cHnical picture of the disease as in 
parenchymatous or interstitial keratitis. Pannus also has vessels. They 
are not in the cornea but are in new tissue deposited upon it. 



The Practice of Osteopathy 221 

Symptoms appearing in keratitis: 

1. Ciliary injection or a red area encircling the cornea. If the 
keratitis is severe there will be considerable inflammation of the con- 
junctiva which may hide to some extent the ciliary injection. 

2. Iritis or iridocyclitis may set in. The iris and ciliary body 
are in such intimate relation with the cornea that these structures are 
very subject to involvement in any severe keratitis. With iritis would 
come danger of synechiae or adherence of the iris to the anterior sur- 
face of the lens. 

3. Hypopyon. — In suppurative keratitis there is some exudate into 
the anterior chamber of the eye. This exudate drops to the bottom of 
the chamber and looks like pus had gathered in the bottom of the aque- 
ous. This condition is called hypopyon, 

4. Other symptoms which are frequently prominent are dimin- 
ished vision, pain, photophobia, excessive lachrymation and ble- 
pharospasm. Edema of the lids and conjunctiva may occur. 

Intelligent treatment of keratitis of course is based upon the exact 
conditions present. Great care in diagnosis and treatment should be 
exercised. 

Ulcer of the Cornea 

Inflammation of the cornea sets in from some cause. There is an 
infiltrate into the substantia propria. A spot becomes cloudy and the 
surface over it becomes dull; at this point the epithelium breaks down 
or exfohates and the loss of substance in the parenchyma is the begin- 
ning of an ulcer. 

Cause. — The cause may be constitutional or local. The causes 
usually thought of from the medical standpoint may be noted in such 
books as "Diseases of the Eye" by De Schweinitz or Weeks. I wish 
especially to call attention to the fact that there is frequently a pri- 
mary and underljdng cause of corneal ulcers not mentioned in any med- 
ical texts, i. e. the osteopathic lesion. By this I mean more than the 
spinal lesion although the subluxation lesions that result from the occiput 
to the fourth dorsal are of most importance. Any tension or change of 
tissue in the cervical region that may interfere with perfect freedom of 
circulation of blood to the tracts and centers in the cord, is to be consid- 
ered. The osteopath of course should take into consideration all causes 
prhnary and secondaiy and govern himself accordingly. 

Symptoms and Course. — There is a gray area surrounding the 
ulcer at first, also the floor is grayish in color. In this condition it is 



■■ 



222 The Practice of Osteopathy 

known as a progressive ulcer or a foul or unclean ulcer. This cloudi- 
ness or gray area may increase in size and the ulcer keep spreading, or it 
may go deeper even to perforation of the cornea. 

Some ulcers advance or spread on one side and heal on the opposite 
side so that they creep along on the cornea — these are the so-called ser- 
piginous ulcers. 

With corneal ulcers there is irritation, pain, photophobia and in- 
creased lachrymation. There is usually some ciliary injection which is 
an indication of involvement of the iris and ciHary body. If iritis occurs 
there is contraction of the pupil with slow reaction. Hypopyon may 
develop. With iritis and the exudate there is likely to be adhesions be- 
tween the iris and the lens known as posterior synechia. 

A few corneal ulcers are asthenic and do not have irritative symptoms 
and 3^et are dangerous. 

When the ulcer begins to heal it is called retrogressive. Dead 
tissue is cast off; other tissue becomes transparent from resorption. We 
have a clean ulcer. Symptoms disappear and cicatrization begins. 
Vessels extend to the ulcers and soon it is leveled up with the corneal 
surface. Cicatrization may leave it slightly below the corneal level or 
above it. 

If there should be perforation of the cornea from the ulcer there 
may be complications, e. g. keratocele, loss of aqueous, dislocation and 
expulsion of the lens, intra-oculair hemorrhage, flattening of the cornea, 
fistula of the cornea, glaucoma, intra-ocular suppuration, prolapse of 
the iris into the opening, etc. These complications and sequelae that 
occur occasionally will not be considered here. 

After healing is complete by cicatrization there is opacity of the 
cornea in proportion to the depth and size of the ulcer. In months and 
years of time there is some clearing of the opacity so that small super- 
ficial opacities maj'- become invisible. 

Treatment of Corneal Ulcers. — Most ulcers of the cornea are 
quite amenable to proper treatment and the prognosis is favorable. 
Neglect or wrong treatment is very dangerous. The treatment is local 
and constitutional. Often the ulcer is kept going by unwholesome con- 
stitutional conditions. 

Local Treatment. — This varies according to the stage of the ulcer, 
whether progressive or retrogressive. In a progressive or foul ulcer if 
due to trauma any foreign bodies should be removed. If the ulcer is a 
result of pathology of the conjunctiva it is of primary importance to 
treat the conjunctival condition. 



The Practice of Osteopathy 223 

In mild cases of ulcer a dressing over the eye with atropine |% to 
keep the pupil dilated is sufficient local treatment. The bandage protects 
the eye from bright hght and other environment and the atropine puts 
the iris and ciliary body at rest preventing compHcations and giving na- 
ture her best chance to work. 

If the ulcer is rapidly progressive, warm compresses an hour or two 
a day are good; iodoform sprinkled on the ulcer or actual cautery may 
be used. In the retrogressive stage (clean ulcer) healing has begun 
and we desire to get as near as possible a resistant transparent cicatrix. 
Yellow oxide ointment is useful at this stage. 

Osteopathic. — The local measures just mentioned are not incom- 
patible with osteopathic theory or practice. They are merely adjunc- 
tive in getting nature's reaction toward normahzation, as also are hot 
and cold apphcations. Osteopathy comes in now in a most important 
and fundamental way with the constitutional and specific lesion treat- 
ment. The bulbo-spino-sympathetic-ciliary arc has been men- 
tioned and explained. Through this important nerve connection with 
the eye, profound and wholesome effects on the eye may be gotten by os- 
teopathic treatment. Frequently lesions of the occiput, cervicals and 
upper dorsals wiU affect the integrity of the ocular structures through 
disturbances of nerve and blood supply. 

The stomach, bowels, Hver and kidneys should be carefully noted 
in corneal ulcers. Poor circulation, indigestion, constipation and auto- 
intoxication may have an important bearing on the recovery of the ul- 
cer. 

Xerosis or Keratomalacia 

This is a disease of the eye in children due to insufficient nutrition 
of the cornea. Hereditary influences, depleting diseases and lesions 
affecting the trophic nerves to the eye are causes. 

Treatment consists of building up the nourishment of the child, 
correction of lesions and careful dieting. Hot applications to the palpe- 
bral region helps to bring the blood supply to the eye for local effects. 

Keratitis Neuroparalytica 

This disease is due to a paralysis of the 5th cranial nerve. The 
cornea becomes slightly cloudy. The epithelium gradually sloughs 
away. An ulcer may or may not form. Pain and lachrymation are 
absent because of paralysis of the trigeminus. There is usually ciliary 
injection. 



224 The Practice of Osteopathy 

Treatment. — The most important treatment for this unfortunate 
condition is manipulation to restore the integrity of the 5th cranial nerve 
and the blood supply to the eye. Cervical, spinal, nasal, nasopharynx 
treatment should be given. Spring the inferior maxilla. 

A drop of atropine (1%) should be used locall}^ because of the ciliary 
injection. Warm compresses used locally will help. The heahng usually 
leaves some opacity of the cornea. Keep the eye bandaged to protect 
the cornea. 

Pannus 

This form of keratitis is superficial and is characterized by the for- 
mation of blood vessels in the cornea. It is caused by some irritative 
influence. Most often it is a complication of trachoma. 

If the irritation can be removed the vascularity gradually recedes, 
leaving a clear cornea unless the deeper structures of the cornea have 
been involved. 

Phlyctenular Keratitis 

This disease is an involvement of the cornea with an eczematous 
process similar to phlyctenular conjunctivitis. There is more likely to 
be ciliary injection and iritis, in wliich case atropine should be used. 
The treatment is the same otherwise as for phlyctenular conjunctivitis. 

Parenchymatous or Interstitial Keratitis 

This is shown by a diffuse inflammatory infiltration of the sub- 
stantia propria of the cornea. Part or whole of the cornea of one or 
both ej'CS may be involved. Very fine blood vessels may invade the 
deep structures of the cornea. 

Cause. — SyphiHs, tuberculosis, rheumatism, diabetes and rachitis 
are systemic diseases found back of this trouble. 

Symptoms.— Irritation, lachrymation, photophobia with ciliary 
injection are the chief symptoms. 

Treatment must be local and constitutional. 

Locally atropine should be used. Dark glasses should be worn or 
the patient must be kept in a dark room. Treatment to the trigeminal 
nerve and tissues of the orbit should be given. 

Constitutional treatment should be spinal with the idea of arous- 
ing all the forces of the body to greater activity. Careful dieting should 
be followed according to indications. 

The infiltration and blood vessels will ultimately disappear. Some- 
times enough may remain to cloud the vision. 



The Practice of Osteopathy 225 

Diseases of the Iris and Ciliary Body 

The iris and ciliary body have the same blood and nerve supply. 
That is, they are supplied by the same set of vessels and nerves. For 
this reason it is practically impossible to have an iritis absolutely inde- 
pendent of a cyclitis or some inflammation of the ciliary body. If the 
iris is the primary seat of the trouble there are certain symptoms that 
may indicate such a state. However, when we are treating the iris or 
diagnosing conditions of the iris we must remember that the ciHary body 
is very likely more or less involved and may be the primary seat of the 
trouble. 

In iritis there are some symptoms which are caused from the hyper- 
emic condition of the eye, such as a slight change in color. The pupil 
becomes rather inactive, there is some ciHary injection with photo- 
phobia, lacrymation and' pain. In case of an exudate in the iris there 
may be thickening, and the exudate in the anterior chamber of the eye- 
will form a hypopyon. Sometimes the small vessels will break and 
there wiU be a Uttle bleeding which will be mixed with the debris in the 
bottom of the anterior chamber. This is known as hyphemia. There 
are likely to be adhesions between the iris and the anterior capsule of the 
lens known as posterior synechia. The pupil is more or less irregular. 
If atropine is dropped into the eye to dilate the pupil, parts of the edge 
of the pupil will be adhered while the Other parts dilate making it very 
irregular. 

In case of cyclitis there is an exudate from the ciliary body into the 
posterior chamber. This may cause a total adherence of the iris to the 
crystalHne lens. With the ophthalmoscope, opacities in the vitreous may 
be noticed. These are exudates. The tension of the eye is liable to in- 
crease a little at first but as the exudates absorb there is more or less 
softening. Vision is low. Also in cyclitis there is ciliary injection, 
photophobia, lacrymation and pain, similar to that of iritis. Pressure 
on the eye ball will reveal a very tender condition around the sclerocor- 
neal junction or over the area of ciliary injection. 

The causes of iritis, cyclitis or iridocyclitis frequently are systemic 
conditions and infection such as syphihs, rheumatism, gonorrhea, tuber- 
culosis, infectious diseases and metabolic changes. It may be of trau- 
matic origin or sympathetic. Fuchs says "There are many cases of 
iritis for which no cause can be discovered and therefore which cannot 
be placed under these causes." We agree with him and advance the 
theory of cer\dcal and upper dorsal lesions or trouble in the sinuses, nose, 



226 The Practice of Osteopathy 

nasophaiynx or throat. No doubt osteopathy can throw some impor- 
tant light on the causes of diseases of the iris and ciUary bod3^ The 
nose and throat should be examined in all these cases. 

Treatment. — Atropine must be used in the sore eye to put the iris 
and ciliary body at rest and dilate the pupil to draw it back from the 
lens so that adhesions may not form. Warm compresses will give much 
comfort. Sweating should be brought about. All fluid should be re- 
duced to a minimum. Diet should be very moderate and the bowels 
kept unusually free. The eye should be protected by dark goggles. 
Thorough treatment of the neck and upper dorsal region with attention 
to the nose and throat should be given. Constitutional treatment should 
be given according to the indications mentioned under causes. If an- 
nular synechia or total posterior synechia form or there is atrophy of the 
eyeball operative work may be needed. Also for injuries, tumors, anom- 
alies and so forth of the iris see the latest medical works on this sub- 
ject. 

Diseases of the Choroid 

The choroid is the vascular tunic of the eye. With the iris and 
cihary body it forms the uvea. The iris and ciliary body are rich in 
nerve terminals and when inflamed ; pain is a prominent symptom. The 
choroid has no sensory nerve terminals. When it is involved alone ; pain 
is not present however severe the pathology. Embryologically Desce- 
met's membrane is a part of the uvea. When the uveal tract is dis- 
eased we frequently note symptoms of a descemetitis as a turbidity of 
the anterior chamber and spots on Descemet's membrane. When one 
part of the uvea is inflamed the tendency is to pass to the other parts be- 
cause of the intimate blood supply. 

Choroiditis 

There are many forms of choroiditis given by writers according to 
the clinical picture and the pathology. 

Symptoms. — No pain is experienced unless there are complica- 
tions. Vision is altered in some degree. The use of the ophthalmoscope 
may reveal opacities in the vitreous. Pigmentation spots and exudation 
may be noted in the fundus. In disseminated choroiditis spots of exu- 
date appear in the fundus which go on to atrophy, leaving irregular cir- 
cular light patches. 

Treatment. — In all forms of choroiditis careful diagnosis of con- 
stitutional conditions should be made and treatment given according to 
indications. 



The Practice of Osteopathy 227 

Nasopharynx and orbital treatment as outlined under manipu- 
lation for diseases of the eye should be given. 

Rest and protect the eyes. Secure free elimination. 

Panophthalmitis 

By injury or otherwise pathogenic germs are introduced into the 
eye. The trouble begins as a suppurative choroiditis and rapidly 
spreads to all the eye structures. The vitreous chamber becomes filled 
with pus. 

Symptoms. — Pain is severe and sight is lost early. The conjunc- 
tiva and lids are much swollen. There is a mucopurulent discharge. 
The cornea becomes gray and may slough. In about two weeks the 
inflammation subsides and the globe passes into atrophy. 

Treatment. — Elimination must be thorough. Spinal treatment 
for keeping up strength. Cervical, upper dorsal and nasopharynx treat- 
ment for the eye. Moist hot compresses to the eye. Operation, incision 
for drainage, or evisceration may have to be performed. 

Sympathetic Ophthalmia 

The other eye may become inflamed by the process from the panoph- 
thalmitis passing around through the circulation or the continuous struc- 
tures. All symptoms of a general inflammation appear and vision grad- 
ually diminishes. 

Treatment. — In panophthahnitis of one eye always watch the other 
eye closely. If it becomes irritable or shows any signs of being affected 
the diseased eye should be promptly removed, especially if vision is lost 
in that eye. If no irritation occurs, continued conservative treatment of 
the panophthalmitis may result in a subsidence of the disease without the 
well eye becoming affected. 

Sympathetic inflammation rarely develops earlier than a month 
after injury to the exciting eye. Sooner than that or even a few min- 
utes after injury there may be some signs of sympathetic irritation and 
the symptoms continue with no evidence except a sHght circumcorneal 
injection. It should be treated hke iritis. A thorough toning of the 
system by spinal treatment should be given. Order a limited diet. 
Secure free elimination. 

Glaucoma 

Glaucoma is essentially an increase in the intraocular pressure. 
All other symptoms of the trouble may be traced to this condition. 

In Primary Glaucoma the increase in pressure sets in without 
any discoverable antecedent disease of the eye. 



228 The Practice of Osteopathy 

In Secondary Glaucoma the increase in pressure is due to some 
other disease of the eye. It is a symptom, a compHcation or accessory 
and is confined to the eye diseased. 

Primary glaucoma affects both eyes, but not always at the same 
time. Fuchs says primary glaucoma constitutes about 1% of all eye 
diseases. It is often mistaken for iritis or iridocycKtis and treated with 
atropine which is contraindicated. It may be regarded as beginning 
cataract and time lost in expecting it to become ripe. These delays 
and wrong treatment have caused much bhndness. 

Palpation with the finger or the use of the tonometer may readily 
detect any increase in tension. A correct diagnosis must be made early 
and proper treatment instituted if vision is to be saved. 

Primary glaucoma may or may not have signs of inflammation. 
If the tension rises suddenly inflammatory symptoms develop (acute) 
while if the increase in tension develops gradually these sjTnptoms are 
lacking (simple). 

Acute primiary glaucoma — Symptoms. — First stage, rise in 
tension, vision obscured, sees a colored ring around lights, cornea dull, 
pupil dilated and sluggish, some ciHary injection. The attack may clear 
up for a day or for weeks. GraduaUy the symptoms become perma- 
nent after repeated attacks. Second stage, when the attack comes 
there is much pain, visual power fails rapidly, maj^ be edema of the lids 
and chemosis of the conjunctiva, all symptoms become much exaggerated, 
the cornea becomes cloudy. After a violent attack the vision is more or 
less permanently damaged. Third stage, after many attacks the optic 
nerve becomes excavated and atrophy takes place. 

Simple Primary Glaucoma 

Symptoms. — Tension comes graduaUy; no inflammatory signs; 
pupil somewhat dilated and sluggish, the cornea may look slightly smoky. 
With the ophthalmoscope a cupped disc may be noted. There is gradual 
diminution of sight, which begins by contration of the field. 

There are many theories advanced as to the cause of intra-ocular 
tension in glaucoma. (Fuchs, Weeks, De Schweinitz). 

Treatment. — Eserine is used instead of atropine. The object is 
to contract the pupil and draw it away from the side wall of the eye ball 
so the sinus (Schlemm's canal) and the pectinate ligment (the filtering 
angle) may become free. The good effect of this is more marked in 
inflammatory glaucoma. In simple primary glaucoma miotics do little 
good. 



The Practice of Osteopathy 229 

Reports from osteopathic treatment of this condition have been 
favorable in a number of cases. Careful manipulation of the structures 
of the orbit with the finger or with Dr. Ruddy's third finger eye instru- 
ment is good in restoring better circulation of the lymph and blood. 
Special attention to the venous drainage should be given. Treat the 
points of the fifth nerve, the nasopharynx and cervical region, spring the 
jaw. Treat second dorsal. 

Have the patient avoid strong emotions or excitement. Keep the 
bowels free and use only a very bland diet. 

Iridectomy is considered the best operation in glaucoma. 

In the treatment of secondary glaucoma the other diseases or 
complications must be considered in conjunction with the foregoing 
treatment. 

Diseases of the Lens 

Opacities or Cataract 

Symptoms. — Beginning opacities can best be recognized with the 
ophthalmoscope. Advance opacities can be seen at a glance with the 
naked eye. 

Vision is disturbed according to degree and location of the opacity. 
If the opacity is in the center of the lens and the periphery is transparent 
they see better when the pupil is dilated. When the opacities are in the 
periphery of the lens they see better by da}^ Muscsg voHtantes and 
polyopia are present until increasing opacity closes up all clear areas shut- 
ting out these visual perversions. 

There are many clinical varieties of cataracts which may be studied 
in works on ophthalmology. 

Causes. — Some interference with the nutrition of the lens accounts 
for the condition. Heredity is supposed to play a part in some cataracts. 
Rickets, convulsions, traumatism, old age, some drugs (ergot), inflamma- 
tion of iris, ciliary body and choroid are given as causes. Cervical and 
upper dorsal lesions and disease of the throat, nasopharynx and nose 
will interfere with perfect circulation and drainage of the orbit, and 
may well have much to do with many idiopathic cataracts. 

Treatment. — Many cases have been reported cured by osteopathic 
measures. Correct lesions and treat to estabhsh free nerve force and 
circulation of blood and lymph to the orbit. Manipulation of the orbital 
tissues and mild vibration of the bulb are measures of value. More hope 
may be held in symptomatic, toxic, secondary and progressive cataracts. 
The process may be stopped and in many cases there is hope of a clearing. 



230 The Practice of Osteopathy 

Diseases of the Retina 

The retina lines the back part of the eye ball. It comes forward to 
the ora serrata. It consists of ten layers which have been demon- 
strated microscopically. One layer of it passes over the ciUary body and 
back part of the iris to the pupil. The fibers of the optic nerve spread out 
over the retina. The point of entrance of the optic nerve is the papilla. 
It is to the inner side of the posterior pole of the eye. The retinal vessels 
emanate there. The macula lutea is the yellow sensitive spot at the pos- 
terior pole of the eye. The fovea is the center of the macula. The rods 
and cones constitute the external layer of the retina. This layer is the 
light perceiving stratum. For vision to be perfect all the other layers 
must be perfectly transparent. The visual purple is a chemical substance 
in the rods that gives the retina a purplish-red color. The Hght shining 
into the eye forms images which are converted into nervous stimuli by 
chemical action of the visual purple and by physical changes and fibril- 
lations in the rods and cones. 

Retinitis 

Symptoms. — The ophthalmoscope must be used in diagnosis. 
There is at first cloudiness of the retina; the outlines of the papilla 
become indistinct. We may note light patches of exudates. The ves- 
sels are more tortuous and often there are hemorrhagic spots. Opacities 
in the vitreous due to the exudate may be seen. Vision is disturbed in 
proportion to the inflammation. Weeks or months are required for 
recovery. Atrophy may set in and cause blindness. 

Cause. — Many general diseases are found back of this trouble, e. g. 
albuminuria, diabetes, leukemia, syphiHs, gout and arteriosclerosis. 
Idiopathic cases occur with none of these diseases present, which gives a 
field for osteopathic research. 

Treatment should be directed against the general disease when 
present. For local effects treatment should be given to all the centers 
and localities that affect the trophism, nerve supply and circulation to 
the e.ye. Protect the eye by dark glass or confinement to a dark room 
and complete rest. Keep the bowels free and produce diaphoresis. 

Optic Neuritis 

This disease when manifest in the eye ball is called papillitis. If 
back of the bulb it is retrobulbar neuritis. 

Symptoms of papillitis. — Pupils are dilated and sight diminishes. 
The color of the papilla is altered to a white, reddish or gray and may 



The Practice of Osteopathy 231 

show extravasation of blood. The papilla is swollen (choked disc), the 
arteries are thin and the veins are engorged. It takes months for the in- 
flammation to clear. Atrophy is likely to occur. 

Causes. — Brain diseases are the most frequent cause, e. g. tumors. 
Syphilis, febrile diseases, nutritive disturbances, lead poisoning, hered- 
ity and growths in the orbit are cited as causes. 

Symptoms of Retrobulbar Neuritis. — There is little or no change 
in the papilla. The diagnosis must be made mostly from the way the 
vision is affected. The rule is a central scotoma in the field of vision. 
The first colors to disappear are red and green. In the acute form there 
is quick disturbance of vision. The eye looks normal outside and shows 
practically no change inside. 

Cause. — Toxemia, cold, influenza; nasal, nasopharyngeal and sinus 
disease (ethmoids), and infectious diseases are causes. Idiopathic in- 
flannnation of the optic nerve is noted by most oculists. Here the pro- 
found effects of spinal lesions upon the eye adds some important fight. 

Treatment of Papillitis and Retrobulbar Neuritis. — In each 
individual case the treatment requires consideration of the causal fac- 
tor. There may be required constitutional treatment in many cases. In 
others the cause may be found in the nose, nasopharynx, or spine. Ef- 
fort should be made to remove the lesion in each case. Diaphoresis will 
aid in acute stages. 

Atrophy of the Optic Nerve 

There are many causes for this condition such as optic neuritis, 
meningitis, acute infectious diseases, locomotor ataxia, arteriosclerosis, 
nasal disease, syphifis, traumatism, alcohofism, exposure, embolism of 
the central retinal artery, diabetes and poisoning. Diagnosis must de- 
termine the original cause. 

Treatment. — I have mentioned conditions in the nose as frequently 
accounting for various eye troubles. If these atrophies of the optic 
nerve can be gotten early, many of them wiU be influenced very favor- 
ably by osteopathic treatment. Spinal treatment to direct the circu- 
lation to the area of the orbit at the base of the brain is beneficial. Regu- 
lation of the patient's diet, habits, methods of living and so forth is im- 
portant. Excessive mental strain, excessive sexual intercourse and 
stresses of every kind should be prohibited. Special treatment should 
then be given according to the causal factors entering into the case. 
Eye Strain and Its Reflexes 

For the subject of refraction and refractive errors such as the different 
forms of hypermetropia, myopia and astigmatism the reader is referred 



232 The Practice of Osteopathy 

to the many excellent works on ophthalmology which cover these sub- 
jects quite thoroughly. They are only used here in the relation to eye 
strain and its reflexes. The osteopathic logic here given should be com- 
bined with a reading of the refractive errors in such works as Fuchs, 
Weeks, De Schweinitz and others. 

Asthenopia 

Eye-strain, wealc siglit or astlienopia embraces the group of 
symptoms dependent upon fatigue of the ciliary muscles or of the extra- 
ocular muscles. 

There are three varieties of asthenopia. (1) Retinal or nervous, 
(2) muscular and (3) accommodative. 

The s>Tnptoms are headache — frontal, fronto-temporal or fronto- 
occipital. It may extend into the neck between the shoulders. Eye 
balls may be tender, diplopia at times, may be photophobia, lachryma- 
tion, congestion of the eye, itching and burning of the Hds. 

Accommodative Astlienopia. — In this form the cihary muscle is 
fatigued. The cause is usually over-use of the eye when hyperopia and 
astigmatism exist; sometimes in myopia or presbyopia. 

Treatment. — In this form the treatment is the proper fitting of 
glasses and improvement of the general health. 

Muscular Astlienopia is due to tiring of the extraocular muscles, 
usually the internal rectus. This may result in a phoria or a non-para- 
lytic squint. 

Ametropia may exist but asthenopia may come even in emmetropia 
due to over-use of the eye. 

Treatment. — Correct ametropia if present, with glasses. Exer- 
cise the weakened muscle. Correct the nerve supply to the weak muscle. 
Treat cervical and upper dorsal. Manipulate tissues of the orbit. Spring 
the jaw. Correct any nose and throat pathology. 

Nervous, Neurasthenic or Reflex Asthenopia — The cause is 
supposed to be some functional disorder, more often found in females. 
May be due to too dim or too bright light, over-use of the eyes. Hysteria 
may follow ametropia. 

Treatment. — Often the treatment is troublesome and the case is 
very obstinate according to old school methods. Rest, hygiene, general 
health and habits are looked after. The cause must be found or the 
treatment cannot be specific. 

These are the different forms of eye strain as ordinarily classified. 
Now as we stud}^ the reflex symptoms from these and attempt to trace 



The Practice of Osteopathy 233 

out the reflexes from an osteopathic point of view, we may find some 
more definite causes of these conditions and consequently some methods 
of treatment not found in standard text books might naturally suggest 
themselves. 

Reflex symptoms that have been traced to eye strain by ophthal- 
mologists are as follows : 

Constipation, indigestion, heart-burn, nausea, vomiting, nervous 
attacks, fear of impending calamity, irritabihty, despondency, insomnia, 
restless sleep, epilepsy, nervous twitchings and eneuresis. All these 
symptoms have been seen to disappear after eye strain was corrected. 
There is no absolute way of proving that all these symptoms have existed 
because of eye strain. The existence and disappearance of some of them 
at the time of treatment for eye strain may be a coincidence. It is evident 
that eye strain in varying degrees may produce a train of symptoms sim- 
ilar to many above mentioned. 

A patient, nervous, anxious, uneasy, and despondent, constipated, 
and having some indigestion, showed on examination contractures and 
tenderness at the third dorsal. It was found he was suffering from eye 
strain from over-use of glasses that were too strong for him. The 
eyes were refitted. He was wearing a 

(R)+4.50 D. S. = +.50 cyl. Ax. 180. 

(L) +4.50 D. S. = + .50 cyl. Ax. 90 
for close work and a (R)+2.00 D. S. = +.50 cyl. Ax. 180 
(L)+2.50 D. S. = +.25 cyl. Ax. 90 
for distance. The new glasses were — Reading — 

(R)+3.00 D. S. = +.25 cyl. Ax. 180 

(L)+3.00 D. S. = +.25 cyl. Ax. 180 
Distance : 

(R) + 1.50 D. S. = +.25 cyl. Ax. 180 

(L) + 1.50 D. S. = -l-.25 cyl. Ax. 130 
He was fitted two years previously. At that time the stronger 
glasses were correct. Eyes change more or less constantly, especially 
between the ages thirty-five to fifty-five years. When glasses are fitted, 
a weak ciliary muscle after a rest may become stronger and allow weaker 
glasses to be worn. 

If a young person is fitted for myopia, in a few years he may dis- 
card his glasses as presbyopia develops. A person fitted correctly, who 
has a strong ciliary muscle may not be able for awhile to see as well with 
the glasses as without them. After they are worn awhile the ciliary 
nmscle will cease its efforts to accommodate so much and the glasses 



234 The Practice of Osteopathy 

give the desired effect. In some cases the doctor's reputation to fit glasses 
proper!}^ may suffer at the hands of such people who sometimes refuse 
to take glasses, or after getting them refuse to wear them. 

In the case of the man just mentioned a refitting quieted the nervous 
symptoms — he became more cheerful and ceased to worry. Indigestion 
and constipation improved. The soreness and contractures were over- 
come in a few treatments. 

Now let us ask the question, why is it that eye strain will cause 
nausea and vomiting? Also why will indigestion affect the ej^es by 
causing "spools" in the vision'^ 

A little osteopathic logic, based as it always is or should be, upon 
anatomy and physiology, may throw some light on this subject. No 
doubt every one of us has demonstrated many times clinically that 
indigestion from over-eating will cause soreness and contractures at the 
third and fourth dorsal, the nerve center in the spine for the stomach. 

The reflexes between the viscera and the eye are complex and diffi- 
cult to follow. In giving the probable course of the nerve reflexes from 
the optic nerve to the third nerve Dr. Louisa Burns suggests the follow- 
ing: "The nerve elements of the retina start the impulse; it passes over 
that portion of the optic nerves which enter the anterior quadrigeminates, 
the cells of the quadrigeminates where the impulses are coordinated, 
then by axons of these cells to the lateral or viscero-motor nucleus of 
the third nerve, thence to the ceUs of the ciliary ganglion, and by the 
non-medulated (sympathetic) fibers of these, the short ciliary nerves to 
the non-striated muscles concerned, viz: the ciliary muscle, some fibers 
of the levator palpebrse and the spliincter of the iris. " 

The third nerve arises in the floor of the aqueduct of Sylvius from 
two nuclei; a lateral nucleus which is a viscero-motor group of nerve 
cells, and a central nucleus or a somato-motor group of cells. The som- 
ato-motor nucleus supplies all the extrinsic muscles of the eye except the 
external rectus and superior oblique which are supplied by the sixth and 
fourth respectively. The nasal branch of the ophthalmic division of the 
5th sends fibers to the ciliary muscle. Association fibers connect the 
nuclei of the 3rd, 4th, 6th and 7th. The evidence is in favor of the 10th 
or pneumogastric having such association fibers. 

We noted four places in the brain to which the optic tracts go before 
the radiations reached the center of sight in the occipital lobe. If we 
cannot follow all the reflexes through the brain and cord at least with the 
facts we have it is not difficult to imagine abnormal impulses coming 
over the third nerve from a straining of the ciliary nucleus, thence over 



The Practice of Osteopathy 235 

viscero-motor fibers in the lateral horn of the cord, over the white rami- 
communicantes, through the sympathetic ganglia, over the splanchnics 
to the stomach, producing abnormal peristalsis, nausea and vomiting. 
In turn we would have the somato-motor nerves to the muscles affected 
as before described, contraction and congestion of muscles of the spine. 
When we have patients consult us and describe a train of symptoms 
like nausea, vomiting, nervousness, frontal and occipital headache, we 
should have eye strain in mind and inquire for lachrymation, photo- 
phobia, itching and burning Hds and congestion of the eye. Any of 
these things should make us think of testing for ametropia in its various 
refractive errors, as well as a careful spinal and a nose and throat examina- 
tion. General physical and laboratory diagnosis should not be neglected. 

References 

Fuchs's Text Book of Ophthalmology, Duane. 
Headaches and Eye Disorders of Nasal Origin, Sluder. 
External Diseases of the Eye, Greeff . 

Vol. Ill Practical Medicine Series: The Eye, Ear, Nose and Throat by Casey A. 
Wood, Albert H. Andrews, Geo. E. Shambaugh. 
Diseases of the Eye, Weeks. 

Diseases of the Eye, Ear, Nose and Throat, Posy and Wright. 
Diseases of the Eye, De Schweinitz. 
Diseases of the Eye, May. 

Text Book of Ophthalmology, Roemer and Foster. 
Diseases of the Eye, Jackson. 
Ophthalmic Surgery, Meller. 



236 The Practice of Osteopathy 



DISEASES OF THE EAR, NOSE AND THROAT 

By J. Deason 
Diseases of the Ear 

Methods and Technic of Examination. — The external ear may 
be examined by direct inspection with or without the aid of artificial 
light. The external auditory meatus may be examined by means of a 
simple conical ear speculum and reflected light from a head mirror. This 
method requii'es considerable practice but efficiency can and should be 
attained because it can be used under all conditions and therefore is a 
reliable method. 

The Holmes electric am-oscope which we use and recommend fo^ 
examining the meatus and ear drum, is very efficient but like other elec- 
trical equipment is not always dependable. There are many electrical 
equipments for examining the ear, but so far I have found none other 
than the one above mentioned that is worth space in an instrument cabinet. 

To examine the meatus, grasp the pinna and draw it firmly upward 
and backward. This tends to straighten the canal so that the aural 
speculum may be inserted well into the external canal. It must be re- 
membered that the auditory canal is always sensitive and while there is 
really httle danger of doing any harm by exercising ordinary care, the pa- 
tient is always afraid of being hurt and one can accomphsh better results 
by practicing careful technic. 

If the electric auroscope is used, the e3^e should be placed very close 
to the lens and every part of the canal, waUs and drum membrane care- 
f uUj^ examined. The Holmes auroscope has a small tube and bulb, pres- 
sure upon which will vary the air pressure in the meatus and cause the 
drum to move. This must be done very carefully because in very thin, 
atrophic membranes there is soma danger of ruptiu'ing the drum. 

Diseases of the Auditory Meatus 

Inspissated Cerumen, or hardened ear wax is one of the most 
common affections of the meatus. The cause in some cases can be traced 
to lesions of the mandible, but in many cases the cause is unknown. 

Treatment. — Protect the clothing l^y means of a towel or rubber 
neck piece. By means of a soft rubber ear syi'inge, wash the canal thor- 
oughly by forcing warm soap solution into it. I prefer concentrated 



The Peactice of Osteopathy 237 

liquid castile soap (any good soap will do) diluted about one to four in 
water as warm as the patient can bear it. The soap solutioxi is con- 
tained in a pus bowl held tightly against the neck under the ear. There 
is little danger of using too much force with the soft rubber syringe. 

In most cases the hardened cerumen will be dislodged by the syring- 
ing only. If this cannot be done, it may be well to discontinue the treat- 
ment until the following day. The solvent action of the soap solution 
wiU further reduce the hardened mass and it usually can be removed by 
syringing the following day. This method is preferable in many cases 
because patients disHke the pain which usually accompanies the use of a 
curet. 

The dull loop cm-et is the most efficient and safest instrument for re- 
moving hardened cerumen that the syringe may fail to dislodge. This in- 
strument must be used with great care because the membranes, long 
protected by the covering of cerumen are hypersensitive and bleed easily. 

After removing the cerumen, the canal should be thorouglily dried 
and lubricated with some non-irritating lubricant. It is also well to 
place a small pledget of absorbent cotton into the external opening to 
protect the sensitive membranes from the cold, an- and dust. 

In drying the canal I prefer to use a small aluminum applicator, 
twisting a smaU piece of absorbent cotton on the end in such a way as 
to cover the tip well, thus making any injury from its use impossible. 

Atrophic Meatus 

Sensitive or itching ears as the patient commonly describes it, is a 
very common disease caused by any atrophic condition of the membranes 
of the auditory meati and frequently found in common with auditory 
or other cranial nerve deficiency or degeneration. The du'ect cause of 
the UTitation is the collection of particles of dry cerumen. 

Treatment. — The local treatment consists of syringing with warm 
(118° to 120°F) soap solution until all of the scaly cerumen has been 
removed. The canal is then dried and lubricated as described above. 
Several such treatments may be required after which I prefer the use of 
the continuous irrigating ear cup, using salt mixture instead of the soap. 
The same salt mixture as is recommended for nose and thr jat irrigation 
is satisfactory. After such irrigations the application of phenol-glycerine 
(10% phenol in glycerine) seems to be an efficient treatment. 

The local treatment must, of course, be accompanied by corrective 
treatment to the mandible and upper cervicals. 



238 The Peactice of Osteopathy 



Furunculosis 



There are three acute affections of the ear which may usually be 
diagnosed from their points of tenderness or pain. Pain upon moving 
the lobe or pinna indicates furunculosis. Pain on pressure posterior 
to the angle of the jaw or externally in front of the ear indicates middle 
ear infection and pain on pressure ov^er the mastoid region suggests 
mastoiditis. 

Probably the most common of the painful diseases of the external 
meatus is fm'unculosis, which is a sub-cutaneous infection of the lining 
membrane of the meatus. The point of swelling may usually be seen 
but in some cases the entire canal is closed. 

Treatment. — In all cases of occluded pus, drainage must be ob- 
tained, but in the early stages of furunculosis, it is not always possible 
to determine the place of " pointing" or the most desirable point to lance. 
As soon as the place of "pointing" can be located it is advisable to lance 
deeply by means of a curved paracentesis knife. The parts are thor- 
oughly cleansed and anesthetized by applying phenol and neutralizing 
with alcohol. The external parts are first painted with alcohol to prevent 
"burning" from any phenol which may be dropped upon them. A 
small cotton apphcator is used, applying the concentrated solution of 
phenol or the crystals (using only a small amount of phenol) to the af- 
fected parts and immediately neutralizing with alcohol. Care must 
be observed not to apply any phenol to the drum membrane and the 
operator must be sure that the action of the carbolic acid is completely 
neutralized by a Hberal application of alcohol. 

The knife blade is placed beyond the furuncle, its curved point turn- 
ed outward and quickly drawn forward through the furuncle, cutting 
deeply. The canal is then packed with a pledget of cotton dipped into 
phenol-glycerine. 

If the place of pointing cannot be seen, palliative treatment may be 
appUed by thoroughly cleaning the meatus, drying and applying a phenol- 
glycerine pack. Heat may be apphed by means of a therapeutic lamp. 
Any electric light bulb or the dry electric pack will do. The external 
parts are well lubricated with paraffin oil and the heat applied contin- 
usously or intermittently until the pain is relieved. 

Infection of the Meatus 

Infections of the meatus are frequently secondary to, or accompanied 
by furunculosis. The treatment, therefore, is similar to that of furuncu- 
losis. 



The Practice of Osteopathy 239 

Always try to locate the point of infection, lance or curet, apply 
phenol or other chemical germicide, neutralize, dry and pack with phenol- 
glycerine. After the point of infection has been thoroughly drained, 
cleanliness and protection from dust or further infection is all that is 
necessary. 

In all cases of infection of the external meatus, suspect middle ear 
abscess as a cause. There may be a pin-point opening through the 
drum, from which the infection has originated and is being maintained. 

Otomycosis or fungus infection of the auditory meatus is rare. 
It usually resembles other infections symptomafcically, but often without 
pus. A microscopic examination will serve to diagnose the condition. 

The treatment consists of thorough cleansing, drying and the free 
apphcation of alcohol. Alcohol is dropped into the ear until the canal 
is full and a pledget of cotton applied to retain it. Usually two or three 
applications are sufficient to effect a cure. 

Eczema of the auricle and meatus is of two types, the squamous or 
scaly form and the sclerotic form. Both forms are chronic and may be 
readily diagnosed by the appearance. 

Treatment. — Some cases are very difficult to cure but we have 
had excellent results with the following treatment: Careful adjustment 
of cervical and mandibular lesions; thorough treatment of any local in- 
fections of head or neck; direct application of phenol-glycerine, local 
cleanhness and protection from irritation. 

Diseases of the Middle Ear 

Clinically the middle ear consists of the tympanic cavity and its 
contents, the eustachian tube and the mastoid cells. 

Acute Suppurative Otitis Media 

Acute infections of the middle ear result from acute naso-pharyngeal 
affections such as colds, influenza, measles, mumps, whooping cough, etc. 
Bathing in contaminated water often results in infection to the middle 
ear through the eustachian tube. 

Diagnosis. — Earache, pain on pressure under the angle of the jaw 
and sudden deafness are the symptoms. (There are also the common 
febrile symptoms.) The chief physical signs are: redness and bulging 
of drum membrane, and contraction and tenderness of upper cervical 
muscles. 

Treatment. — If the patient is seen before the drum has ruptured 
it is seldom necessary to lance the drum if the proper treatment is given 
promptl3^ 



240 The Practice of Osteopathy 

Drainage must be obtained and maintained by catheter aspiration 
through the tube irrigation of the naso-pharyngeal cavity, irrigation 
of the meatus by means of the continuous ear irrigator and apphcation 
of dry heat over the affected part. Heat is best apphed by means of a 
therapeutic lamp. (Any lamp with reflector that will furnish proper 
heat is efficient as there is no virtue in colored light.) The skin surface 
over the ear, side of face and mastoid region is first well lubricated with 
some mineral oil to prevent blistering and the heat is applied either con- 
stantly or intermittently. A pledget of absorbent cotton dipped into 
phenol-glycerine is placed in the meatus and forced loosely against the 
drum. This should be removed every few hours and a fresh pledget 
put in. 

The neck and upper dorsal muscles should be kept relaxed and ad- 
ju stive treatment given frequently. 

Under this treatment the pain should be relieved and the bulging 
of the drum should disappear in from two to twelve hours. If this is 
not accomplished or if the condition grows worse, the drum should be 
lanced. See some text on otology for technique. In my experience, 
very few cases have required paracentesis. 

It must be remembered that treatment should be continued regu- 
larly and for some time after the pain and other symptoms have been 
relieved or a recurrence is probable. Patients should have daily treat- 
ment until the physician is sure that no comphcation or recurrence is 
likely to result. 

If the patient is not seen until after the drum has ruptured, the 
same treatment may be applied except. the irrigation or syringing of the 
meatus. This, in case of ruptured drum, may force pus into the mastoid 
cells resulting in mastoiditis. Instead of syringing, the auditory meatus 
is cleaned by means of a cotton appHcator or by aspirating with a cath- 
eter. At all times drainage through the meatus must be maintained un- 
til the drum begins to heal. 

Acute Mastoiditis 

Acute mastoiditis results from acute or chronic otitis media. In 
some cases the otitis media may have been only a mild attack. 

Diagnosis. — There is no one symptom that is positively diagnostic 
but a numl^er of signs and sjTiiptoms must be considered as follows : 

1. Always suspect mastoid complications in acute otitis media 
and watch for this comphcation daily. Most cases have some mastoid 
inflammation. 



The Practice of Osteopathy 241 

2. Pain or swelling over mastoid. Pain may not be present, but 
usually is, sonletimes radiating over temples and eye on affected side. 

3. Tenderness on pressure not always present. May be very mark- 
ed. Tenderness extending to tip or above ear means extension of infec- 
tion. If persistent tenderness over tips with marked swelling and dis- 
coloration — operation is indicated. 

4. Swelling, not always present, but sometimes very marked. If 
extreme swelling and bluish discoloration— usually means operation. 

5. Temperature varies from normal to 104° or 105° F. Temperature 
of more than one or two degrees means systemic absorption and suggests 
surgical drainage. Streptococcus or staphylococcus infections cause 
higher temperatures and require drainage earlier than other infections. 

6. Transillumination not positive, but of some value. Like X-ray, 
usually shows dark, because of inflammation, but must rely upon symp- 
toms, as above. 

7. Microscopic. — Stain for pus, bacteria and bone debris. Hema- 
toxylin stain shows dark bone particles if there is bone disintegration. 

8. Blood Count. — If absorption, there will be some variation in 
proportions of leucocytes. Any high leucocytosis shows systemic ab- 
sorption and the natural attempt to overcome the infection. 

Non-Surgical Treatment. — 1. Drainage must be maintained 
from middle ear through tube or drum or both. Catheter aspiration 
through tube. Sometimes gentle inflation to clear the tube, followed by 
aspiration is effective. 

2. If drum is ruptured, aspirate middle ear by catheter or by Moore's 
method or both. This is very important. If no aspirating machine, 
use syringe and pump meatus and tube persistently. Dry meatus and 
keep well open. 

3. Patient should be kept in bed if symptoms are marked, with 
Ught diet and bowels well open. 

4. Heat. — Apply oil or other lubricant over whole side of face 
and head and apply heat by means of 'therapeutic" lamp intermittent- 
ly. Thirty minutes light on and fiifteen minutes light off. The light- 
heat (any electric lamp with reflecting shade will do) is much better than 
hot water bottle or electric pad or sand bag. The heat must be kept 
going day and night if symptoms are marked until the pain has entirely 
subsided. Heat is most efficient in the early stages. After symptoms 
are well marked, the ice pack is more desirable. 

5. If drum is not ruptured, heat may be applied by means of Dca- 



242 The Practice of Osteopathy 

son's continuous irrigating cup. Start at 116° F. and gradually increase 
to 123° F. if patient can bear it. 

Surgical. — If drum has not ruptured and symptoms continue, it is 
best to make free incision of drum, — keep open and apply (2) above. 

Indications for Mastoid Operation. — There are no definite signs, 
symptoms or tests that will determine positively when operation should 
be done. If the ^bove non-surgical methods are practiced, few cases 
will require operation, but many will develop into chronic mastoiditis 
and so it is very difficult to decide whether a mastoid operation should 
or should not be done. It is best to explain thoroughly the possible com- 
plications to the patient and relatives and request them to assume re- 
sponsibility. INIastoid operations are attended by very httle danger 
when properly done. 

Signs and Symptoms Suggesting Operation. — Acute otitis 
media with mastoiditis. 

(1) Persistent pain and swelUng not relieved by non-surgical treat- 
ment. 

(2) Marked protruding of posterior wall or meatus. 

(3) Marked tenderness, swelling and discoloration above ear or 
over tip of mastoid. 

These with temperature of more than.. 102° usually are enough to 
demand immediate drainage. 

(4) Any evidence of extension of pus under skin of neck below tip. 
A positive indication for drainage. 

(5) Any indications of brain or meningeal involvement such as very 
marked and persistent headache, partial or total loss of consciousness, etc. 

(6) Indications of labyrinthine involvement such as marked vertigo, 
etc. 

(7) Sudden cessation of discharge means obstructed drainage from 
middle ear or from mastoid into middle ear and if drainage cannot be re- 
stored by aspiration, this means operation. 

(8) The whole chnical picture must be carefully considered at aU 
times. Take no chances. Advise operation before someone else finds 
it too late. 

Chronic Mastoiditis 

Cause.— Always from unsuccessfully treated acute form or from 
chronic sujopurative otitis media. 

Non-surgical treatment. — See chronic suppurative otitis media. 
We have had a few cases that were seemingly permanently cured by non- 
surgical treatment, but beheve thej^ are rare. 



The Practice of Osteopathy 243 

Indications for Operation. — 1. Recurrent exacerbation of acute 
or chronic otitis media. 

2. Constant discharge which resists treatment for chronic suppura- 
tive otitis media. 

3. Continued pain or recurrent pain and swelling following acute 
otitis media. 

4. Open sinus into mastoid either external or through meatus. 

5. Cholesteatoma. 

6. Symptoms of labyrinthine or brain involvement following acute 
otitis media. 

7. Definite evidence of bone disintegration in mastoid. 

As stated above, none of these are definite indications. The whole 
group of signs and symptoms are to be considered. 

Chronic Suppurative Otitis Media 

Etiology. — Chronic suppurative otitis media usually results from 
an unsuccessfully treated acute otitis media. If in acute otitis media 
there has been bone erosion or extensive destruction of the mucous mem- 
brane by a virulent infection, chronic suppuration is hkely to result. 
A persistent mastoid infection following otitis media is hkely to result 
in chronic otitis media and this is strong argument for early mastoid 
operation. 

1. Otitis media resulting from some virulent infection such as the 
recent influenza pandemic or scarlet fever is always more likely to result 
in mastoiditis and chronic suppuration of the middle ear. 

2. Such infectious agents as streptococcus, staphylococcus, long- 
chain pneumococcus or bacillus influenzae are Hkely to result in chronic 
suppurations. 

3. Lowered vitality from any cause. 

4. Inefiicient drainage from failure to aspirate the Eustachian tube, 
delayed perforation or failure to lance drum sufficiently early. 

5. Mastoid necrosis, which maintains drainage into the tympanic 
cavity. 

6. Abnormal granulations,. polypi, etc. in tympanic cavity. 

7. Chronic inflammation with suppuration of the epipharynx or 
Eustachian tubes. 

8. Cholesteatoma resulting fi-om perforated drum and growths of 
epithelium (extending into the middle ear cavity. 

Diagnosis. — The diagnosis is easy because nearly every case of 
discharging car without pain is chronic suppurative otitis media. The 



244 The Practice of Osteopathy 

determination of the exact nature of the condition present is not onlj^ 
very important but very difficult. 

Differential diagnosis consists in determining the nature of the 
infecting organism and the nature and extent of the pathology. 

1. Direct examination of the external meatus after drying with cot- 
ton applicator usually determines the location and extent of perforation 
of the drum and the general nature of the discharge, whether purulent 
or mucopurulent. Very rarely one finds a serious discharge which means 
a very slight infection or discharge from non-infective inflammation. 
The presence of whitish or greyish pus, mucoid and stringy, usually means 
pneumococcus infection. Greyish, purulent non-mucoid discharge us- 
ually indicates streptococcus or bacillus influenzae infection. Yellow, 
purulent discharge suggests staphylococcus infection. The general ap- 
pearance of the discharge, however, cannot be considered of important 
diagnostic value because most chronic suppurations are mixed infec- 
tions, because of long exposure to external contamination. 

2. After cleaning the meatus, several smears should be made di- 
rectly from the opening in the drum. By staining with methylin blue 
or gentian violet, the nature of the bacterial infection can be determined 
and this is very important. 

By staining another smear with hematoxylin and washing in water, 
any dark irregular particles, bone debris, may be found, which means 
bone disintegration. This too, is very important. 

3. Transillumination is sometimes of value. The mastoid may be 
transilluminated by placing a good rubber covered transilluminating 
lamp over the mastoid and observing the external meatus through an 
aural speculum. If the mastoid is free from infection the light will pass 
through and illuminate the meatus. 

4. The X-ray plate is, of course, the best means of determining the 
nature and extent of mastoid involvement. 

Treatment. — This is certainly one of the most difficult diseases of 
the ear that one is ever called upon to treat and the physician should be 
cautioned against offering a favorable prognosis. Perhaps the most 
difficult thing about its treatment that the doctor has to learn is that 
practically none of the so-called antiseptic washes do any good, but on 
the other hand they often do harm. Certain general principles are im- 
portant and the treatment must depend upon the nature and extent of 
the infection and pathology present in each case. 

The constitutional treatment consists of everything that will in- 
crease the patient's general resistance and certainly all lesions of the cer- 



The Practice of Osteopathy 245 

vical, upper dorsal and mandibles must be properly adjusted, but this 
is not enough. All spinal lesions that may exert an influence on metab- 
ohsm and ehmination are of important consideration. The diet, habits 
and environment of the patient must be considered. 

A careful examination of the naso-pharyngeal tract may reveal some 
other focal infection, such as chronic tonsilhtis, pharyngitis or sinuitis, 
which is maintaining the infection through the Eustachian tube. There 
may be a focal or general infection of some other part of the body, which 
is reducing resistance or causing a hematogenous infection of the tym- 
panic cavity or mastoid cells. 

Drainage must be maintained in all cases, both through the Eus- 
tachian tube by catheter aspiration and through the drum by aspirat- 
ing and drying. If the perforation in the drum is small or in the middle 
or upper part, it should be opened down to the floor so that the con- 
tents may be more easily removed and better drainage estabUshed. It 
is well first to thoroughly cleanse the meatus and tympanic cavity by 
syringing with salt mixture (salt 3 parts, borax 2 parts and soda 1 part, 
a teaspoonful to a half pus bowl of water) at from 116° to 118° F. After 
syringing, the meatus is carefully dried, and the middle ear cavity as- 
pirated through the tube and drum opening. The advantage of this 
simple treatment is thorough cleanliness and drainage with the mini- 
mum of irritation. This treatment given daily or thrice weekly wifl 
often cure the case. 

Staphylococcus and streptococcus infections usually respond to the 
following treatment: After thoroughly cleansing as above, the meatus 
and tympanic cavity is syringed with a one to four or one to five dilution 
of Dakin-Carrel solution (Hyclorite may be used instead) followed by 
aspiration, the fluid being drawn through the tube, thus preventing rein- 
fection from that source. 

Pneumococcus infections do not respond to either of these methods 
of treatment. The pneumococcus, because of its capsule, is not affected 
by antiseptics, but on the other hand the irritation of the tissues caused 
by their use, only gives the infective agent a better opportunity for 
growth. 

In pneumococcus infections we have found the following method 
efficient : Thoroughly cleanse the meatus and middle ear cavity by salt 
mixture syringing, aspiration and drying. The meatus and tympanic 
cavity is then filled with a neutral mineral oil. The oil is also pumped 
through the Eustachian tube. It is the purpose to fill the entire cavity 
and its openings so thoroughly that no air can enter. In some cases 



246 The Practice of Osteopathy 

we have used bismuth paste after the oiHng with excellent results. The 
pneumococcus is aerobic and if all air can be kept away for a consider- 
able time, it furnishes an unfavorable culture environment with Uttle 
irritation to the membranes. 

Surgical treatment. — The presence of bone debris indicates bone 
disintegration in the tympanic cavity or mastoid cells. If the mastoid 
cells are thus involved there is httle chance for direct treatment. If 
such cases do not respond in a short time to any of the above methods of 
local treatment, ossiculectomy or mastoid operation may be necessary. 
Some specialist surgeons claim from 80% to 90% favorable results from 
mastoid operation in such cases. 

Non-Suppurative Otitis Media — Catarrhal Deafness 

Deafness is any impairment of normal hearing and is that symptom 
next to pain and chronic discharge that causes the patient to visit the 
doctor. If acute diseases of the ear, nose and throat could always be 
successfully treated, there would be httle trouble from the symptoms of 
chronic pathology. It must be understood that catarrhal deafness is a 
symptom of chronic otitis media and is, therefore, seldom of recent ori- 
gin. 

Etiology. — Chronic otitis media is nearly always the result of the 
extension of infection through the Eustachian tube and has come from 
some acute or chronic nasopharyngeal infection. Chronic colds, pharyn- 
gitis, tonsilhtis, sinuitis, etc., resulting in acute or chronic otitis media 
either with or without suppuration, constitutes the beginning of catarrhal 
deafness. 

Symptoms. — There is seldom any pain with this disease. Some 
cases have an occasional acute attack with pain and other symptoms of 
acute otitis media. 

Deafness, var5dng with the progress of the pathologic changes, is 
always present. The patient in the early stages will seldom admit that 
he suffers from deafness and often he is honest because he may not rea- 
lize that he cannot hear normally until his otitis media has progressed 
to the second or third stage. Most patients, in fact, do not become 
alarmed about their hearing until it is too late to restore normal hear- 
ing. For this reason, physicians should be on the look-out for such 
conditions and should advise special treatment early. 

The human species in its present environment, depends much less 
upon the organs of special sensation than do the animals of the wild, and 



The Practice of Osteopathy 247 

they may therefore be very deficient in sight, hearing, smell, etc. with- 
out actually reahzing this loss. 

In addition to deafness there are other symptoms such as occasional 
or constant fullness or feehng of "stuffiness" as the patients express it, 
due to partial or complete occlusion of the Eustachian tubes. Tinnitus 
aurium or head noises is very common and often the most annoying 
symptom. Autophony, or the loud sound of the patient's voice to him- 
self, which often causes him to speak low and indistinctly, occurs in the 
later stages. Presbyacusia, or the inability to adjust the hearing appa- 
ratus to variations in pitch, commonly occurs in the second stage and is 
evidenced by the fact that the patient does not hear when more than one 
person is talking. Paracousis or perverted phenomena of hearing, such 
as the better hearing of some persons in a noisy environment, is a symp- 
tom of the third stage of otitis media and often means an unfavorable 
prognosis, so far as marked improvement in hearing is concerned. 

Pathologic Stages. — For convenience of discussion we may con- 
sider chronic otitis media in three stages. 

The First Stage. — The active pathology is limited to the pharyn- 
geal portion of the Eustachian tube with some inflammation of the mem- 
branes of the tjmipanic cavity. Closure of the tube followed by absorp- 
tion of the oxygen causes a decreased pressure in the tympanic cavity 
and thus a retraction of the drum, decreased movement of the ossicles 
and a general decrease in function of all tympanic structures. Deafness 
in this stage may be very marked, especially if the Eustachian occlusion 
has occurred from some nasopharyngeal acute inflammation. There 
may be pain but there is always a characteristic "fullness" and some- 
times dizziness. Deafness in these cases varies with weather changes. 
If proper treatment is had in time, the progress of the pathology can 
be stopped and every case can be restored to normal hearing. 

The Second Stage. — The active pathology has extended through- 
out the Eustachian tube causing marked occlusion and some stenosis. 
There is further inflammation of the tympanic structures with an in- 
crease in the symptoms of the first stage. The drum membrane is less 
movable but there is no fixation of the ossicles. Pressure upon the bulb 
of the auroscope causes movement of that part of the drum to which 
the malleus is attached. The drum is thicker, more retracted, and less 
movable than in the first stage. Presbyacusia is common and often mark- 
ed, but there is no paracousis. More than 90% of these cases can be 
materially improved and many can be made to hear normally if proper 
treatment is given in due time. 



248 The Practice of Osteopathy 

The Third Stage. — The active pathology in the third stage consists 
of an involvement of the entire mucous membrane lining the Eustachian 
tube and tympanic cavity. These membranes are all chronically hy- 
pertropliied. The Eustachian tube, however, is sometimes fairly well 
open, but the ossicular attachments are more or less fixed by hyper- 
trophicd tissue and adhesions and the drum is markedly retracted, thick- 
ened and usually very immovable. The deafness is usually quite marked, 
head noises are commonly present and often ver}^ annoying. Patients 
usually do not notice a variation in their hearing from weather changes. 
Presbyacusia is present in 80% of cases and their hearing for low tones is 
much reduced. 

Unless there is a complicating nerve affection these cases hear well 
by telephone, which means that they can also use an electric hearing in- 
strument to advantage. These cases can never be restored to normal 
hearing, but many of them (30% of my cases) can have some improve- 
ment and in most cases I believe the progress of the pathology can be 
stopped, and this is always well worth while because their hearing is 
likelj^ to be entii-ely lost if something is not done. 

Psychologic Stages. — There are three rather distinct psychologic 
stages in catarrhal deafness. The first, the period in which most pa- 
tients refuse absolutely to admit that they are deaf even to the aurist 
upon whom they call for treatment. They insist that they hear perfectly 
if people would only speak distinctly. This is partially true, because up 
to the third stage of deafness the voice can be fairly well heard if people 
would only articulate clearly. In the second stage patients admit that 
they don't hear well, but insist that they are going to recover normal 
hearing and often resort to various kinds of injurious treatment. In 
the third stage they give up all hope of ever regaining their hearing, 
become morose, and avoid company. These psychic stages do not al- 
ways correspond with the pathologic stages given above. 

Diagnosis. — The external auditory meatus, drum membrane and 
ossicular chain, constitute the apparatus whose function is that of con- 
duction of sound waves to the perception apparatus of the inner ear. 
The function of the conduction apparatus varies inversely with the pro- 
gress of pathologic change in these structures. The perception appa- 
ratus, the structures of the inner ear, are not necessarily affected by mid- 
dle ear pathology, but on the other hand, sounds transmitted by bone 
conduction not only seem louder but they last longer because the "es- 
cape of the excess" of sound thus transmitted is hindered by deficient 



The Practice of Osteopathy 249 

conductive mechanism. This explains why such persons hear well by 
telephone and why the tuning fork, whose base is held to the mastoid 
(provided there is no nerve affection) may be heard for a greater time 
than normal. Likewise the prong of the vibrating tuning fork when held 
near the concha is heard for a shorter time than normal, because of the 
deficient function of the conduction mechanism. 

Tuning forks are known by their number of vibrations per second, 
such as 16, 32, 64, 128, etc. Three or more forks are required to make 
an accurate measurement of the conduction and perception functions — a 
low fork about a 32, for the low tones, 128 or a 512 for the medium tones 
and a 2048 for the high tones. 

A good set of forks should be selected and standardized, i. e., the 
normal bone and air conduction of each fork determined by testing it 
on a number of persons whose hearing is known to be normal. For the 
general practitioner who cares only to get a general idea of the extent 
of the pathology, one fork of medium pitch such as a 128 or 512 will be 
sufficient. 

To measure the function of .hearing, the fork is set into maximum 
vibration, its base held against the mastoid and the patient is asked to 
state when he no longer hears it. This length of time in seconds is re- 
corded as "bone conduction." The fork is then held near the concha 
and the patient again states when he does not hear it. This length of 
time in seconds is recorded as air conduction. 

Normal Hearing 

Tuning Fork Test. — The normal time rate in seconds set of forks 
is as follows : 

Fork 32 64 128 512 2048 4096 

B. C 25 30 30 20 10 

A. C tone 70 90 90 40 20 

The tuning fork test, carefully made, is the only known method of 
measuring the functions of the various structures concerned in audition. 

Tlie Wliisper Test is made by producing a clear whisper from re- 
sidual air only, which should be heard about twenty feet by a normal ear. 

Tlie Watch Test is made by using some loud ticking watch (I pre- 
fer an Ingcrsoll), holding it first near the ear until the patient recognizes 
the tone, and then taking it beyond the hearing distance and approach- 
ing the car until it is heard. I prefer also to move away from the ear until 
the limit is reached and strike an average of this with the above results. 



250 The Practice of Osteopathy 

The average eighteen size Ingersoll watch can be heard for from 100 to 
150 inches by the normal ear. 

The practical test for the patient is his hearing from the spoken 
voice, and is the most reliable so far as permanent results are concerned. 

Low Tone Limit. — The lowest Hmit of hearing is about sixteen 
double vibrations per second, but the lowest practical limit is about 
thirty-two. There are few people with normal hearing and with musical- 
ly trained ears who can recognize a definite tone lower than this, so I 
consider the thirty-two fork sufficiently low for all practical tests. 

Conduction Deafness. — Low tones are lost in tympanic involve- 
ment or conduction deafness, and are diagnostic in such cases, but are of 
no particular value in nerve deafness except when that is compUcated 
by catarrhal deafness. 

Practical Hearing Limits. — The human voice varies from about 
60 to 150 double vibrations per second, and most sounds that we really 
need to hear are less than 700 vibrations per second. This is the reason 
for using the low forks, 64, 128 and 512. 

Measurement of Nerve Force. — To measure auditory nerve 
force, the fork (say the 128, whose normal B. C. is 30 seconds) is set into 
vibration and held gently and with even pressure against the mastoid 
and the patient is asked to tell or signal the doctor when he ceases to 
hear the tone. Two or more tests may be made to determine the pa- 
tient's personal equation, but the use of control forks (the 64 and 512) 
will show any such error. Granting that there is no complicating path- 
ology, tympanic or labyrinthine, the number of seconds of hearing over 
30 will be the patient's auditory nerve force. For example, if he hears 
the fork 30 seconds his hearing will be thirty-thirtieths or normal. If his 
hearing is 25, 20, 15 or 10 seconds, his auditory nerve force will be re- 
spectively 25-30, 20-30, 15-30 or 10-30. 

By means of this method an accurate measurement of the functions 
of hearing can be made and a definite prognosis can be given. I never 
use any of the various named qualitative fork tests for hearing, because 
they have no value to one who employs this system. 

Foot Note — In the chart T is used, meaning that tone is heard, while S indi- 
cates sound but no tone. 

Foot Note — It is not the purpose to give any detailed or differential methods of 
diagnosis because if one cares to treat these diseases he will of course, study a special 
text on this subject. The methods here given are only for the generl practician who 
wishes a general idea of the condition present. 



The Practice of Osteopathy 251 

Summary of Diagnosis of Different Stages of Catarrlial Deafness 
First Stage 

1. Fork 32 128 2048 

B. C. 35 20 

A. C. T 70 40 

2. The drum is only slightly retracted but freely movable. 

3. Whisper heard from five to twenty feet. 

4. Ingersoll watch heard from 30 to 150 inches. 
Second Stage. 

1. Fork 32 128 2048 

B. C. 40 20 
A. C. T 60 40 

Note that the tone of the 32 fork is heard, the 128 fork has increased 
in bone conduction and reduced in air conduction but that the bone-air 
ratio is direct, that is the patient hears longer by air than by bone con- 
duction. Note also that the high fork is stiU normal. 

2. The drum wiU be found retracted but that part to which the 
malleus is attached is still movable when tested with the auroscope. 

3. The whisper is heard from two to ten feet. 

4. The IngersoU watch is heard from six to sixty inches. 

5. Presbyacusia but not paracousia, is present. 
Tliird Stage. 

1. Fork 32 128 2048 

B .C. 45 15 

A. C. S 20 30 

The typical diagnostic points in third stage catarrhal deafness are: 
1. Tone for the 32 fork is lost. 2. There is an inverted bone-air ratio 
for the medium fork. The drum is retracted and the malleus fixed. 4. 
The whisper may be heard at less than one foot or not at all. 5. The 
Ingersoll watch is heard less than six inches from the mastoid. 6. Para- 
cousis Willisiani is present. 

For the general practician this is important because he can make a 
rather definite prognosis. 

Treatment. — The treatment will be given briefly because space 
would not permit ofl engthy discussions of details of methods and technic. 

A careful examination should be made for some source of focal in- 
fection about the nasopharyngeal tract. Chronic or subacute tonsil- 

FooT Note — Note that the patient hears the tone of the low fork, that the 128 
fork has its bone conduction slightly increased (30 to .35) that the air conduction 
is slightly decreased (90 to 70) and that the high fork remains normal. 



252 The Practice of Osteopathy 

litis, phar>Tigitis or sinuitis or root abscess are often a cause, and not 
much will be accomplished in improving the otitis media until these 
focal infections are found and properly treated. The original cause of 
these focal infections may have been some bony lesion, but to successfully 
correct such lesion now does not mean that the source of infection will 
be removed. 

Auto-intoxication from gastrointestinal disease is common. In my 
cases, 80% of the third stage have chronic constipation or other chronic 
gastro-intestinal affection. 

In many severe acute affections of the naso-pharynx the inflamma- 
tory process has left the Eustachian tube occluded or stenosed and the 
pharyngeal fossa filled with adhesive bands. It is not uncommon to 
find the epipharynx and pharyngeal fossa filled with partially atrophied 
adenoid tissue or if the curet method has been used for removing ade- 
noids, there is often connective tissue adhesions and any or all of these 
may prevent the normal ventilation of the tympanic cavity by way of the 
Eustachian tube. 

In such cases sm-gical removal of these obstructions and dilation of 
the tube is necessary. My practice has been to give a general anes- 
thetic (nitrous oxide or somnoform will be sufficient in many cases) and 
by means of an adenotome (La Force or Gradle, I never use a curet) re- 
move all adenoid tissue. Then by means of the finger I carefully remove 
any adenoid tissue in the posterior nares and pharyngeal fossae that the 
adenotome may have failed to get and also dilate the pharyngeal portion 
of the tube by inserting the finger. 

This operation if carefully and thoroughly done and if preceeded 
and followed by the proper surgical cleanliness and supportive treatment, 
will when indicated, accompKsh excellent results. The after treatment is 
even more important because if this is not well done, no results or even 
unfavorable results may occur. The after treatment consists of daily 
irrigations of the nasopharynx, thorough attention to upper thoracic, 
cervical and mandibular lesions, aspiration of the Eustachian tubes and 
other local treatment to the nasopharyngeal membranes. After the 
operation has been done it is best to do no digital manipulation of the 
pharynx for from three to six days. After this time digital treatment, 
gentle dilation of the Eustachian orifice to maintain its patency, stretch- 
ing of the soft palate to re-establish proper nerve function and the appU- 
cation of deep pressure in the pharyngeal fossae to stimulate the otic 
ganghon is important. This treatment is not massage in any sense but 
definite, purposeful, manipulation and if carefully done will be followed 
by excellent results. 



The Practice of Osteopathy 253 

Since the origin of this method of treatment, there has been much 
comment on its value and many have tried or at least they thought they 
tried it with unfavorable results. The causes of failure are, attempting 
treatment in cases impossible of cure, or poor diagnosis, improper tech- 
nic of operator or incomplete operative procedure and inefficient suppor- 
tive treatment. 

It must be understood that not all cases of otitis media even in the 
beginning stages require the above method of treatment or will be bene- 
fited by it. Those cases which have resulted from other causes than 
acute pharyngitis seldom require such radical methods of treatment. 

In every case, the cause must be found and consistent treatment 
given. In my experience, the radical method of treatment has not been 
found necessary in more than twenty per cent of cases of chronic otitis 
media. In the other cases the treatment consists of removing sources 
of focal infection (about forty per cent) and normalizing nasopharyn- 
geal reflexes by osteopathic and local treatment (about forty per cent). 
In aU cases, the treatment must be complete. To remove thoroughly aU 
obstruction from the epipharynx and leave a source of focal infection in 
the tonsils will accompHsh Httle, or to remove carefully all pharyngeal 
obstruction and all sources of focal infection will not restore normal 
functions of the middle ear structures if the osteopathic lesions and gas- 
tro-intestinal perversions are neglected. Surgery in itself, even though 
carefully and thoroughly done, is not efficient treatment and this is why 
the medical specialists fail in this disease. After the necessary surgery 
has been done, then normal tone must be restored to the various tissues 
involved. Normal reflex mechanisms must be re-estabUshed and this 
can be done by thorough and efficient osteopathic corrective work and 
the proper local treatment directly to the structures affected. 

Meniere's Symptom Complex 

This is a form of catarrhal deafness with all the characteristic path- 
ology of the first or second stage, but in which, due probably to sudden 
tubal occlusion, there results a marked variation in the intralabyrinthine 
pressure and there are, therefore, the symptoms of conduction deafness 
combined with labyrinthine involvement somewhat resembhng Men- 
niere's disease. There is dizziness or even vertigo, with head noises, but 
not the marked prostration and nausea which characterizes Meniere's 
disease. 

Treatment. — The treatment is the same as in the first stages of 
catarrhal deafness and the prognosis is always good. The labyrinthine 



254 The Practice of Osteopathy 

symptoms are usually completely relieved as soon as the middle ear is 
ventilated. 

Diseases of the Inner Ear. 

Acute Suppurations. — Acute suppurative diseases of the laby- 
rinth occasionally result I'rom the extension of infection from the tympan- 
mn but they are certainly very rare. Such conditions may result from 
acute suppurative otitis media in which there has been an excessive col- 
lection of pus without rupture of the drum or drainage through the tube 
but this very rarely occurs and after drainage has been estal)lished, laby- 
rinthine infection is hardly possible. 

Diagnosis. — Labyrinthitis is of several forms but in gerneral, 
there are the symptoms of labyrinthine involvement such as : nystagmus, 
vertigo, nausea, vomiting, headache, earache, deafness and febrile symp- 
toms. When labyrinthitis is suspected, an aurist of much experience 
should be called into consultation at once. 

Treatment. — Suppurative labyrinthitis is not in itself a fatal 
disease but dangerous compHcations may result because of the close 
proximity to so many delicate structures. Threatened meningeal infec- 
tion requires surgical drainage, but unless meningeal infection is immi- 
nent, surgery is contraindicated. Since the mortahty, considering dangers 
of compHcations, is not high (about 10%) and since such operations are 
very compHcated and require great surgical skill, we may conclude that 
surgery is generally contraindicated. 

Nonsurgical treatment consists of keeping the patient quiet in bed, 
Uquid diet, and good eUmination. Drainage through the middle ear or 
Eustachian tube must be maintained. 

Deep manipulation of the cervical structures will help to main- 
tain lymphatic drainage but any treatment which necessitates much 
movement of the head should be avoided until the symptoms of vestibu- 
lar irritation have ceased. 

Non-Suppuratlve Labyrinthine Diseases. 

Meniere's Disease. — This disease is caused by hemorrhage into 
the labyrinth with the following symptoms: There is sudden and intense 
vestibular irritation such as vertigo, marked tinnitus, nausea, vomiting 
and complete deafness on the affected side. There may also be cere- 
bral disturbances and loss of consciousness. 

The Prognosis depends upon the extent and severity of the path- 
ology. It is probal)le that those cases in which recovery occurs quickly 
are not true cases of Meniere's disease but have some causes other than 



The Practice op Osteopathy 255 

labjrrinthine hemorrhage. Such cases are perhaps Meniere's Symptom 
Complex. 

The Treatment consists of complete rest in bed, Hght diet, and good 
elimination until the marked irritation has passed. It has been my prac- 
tice to carry out further treatment similar to that of the treatment of 
nerve deafness to be given later. Many of these cases will make com- 
plete recovery. 

Nerve Deafness. 
The term "nerve deafness" is generally used very carelessly to apply 
to any chronic or non-suppurative process of the labyrinthine structures 
other than those mentioned above, which cause impaired hearing. 

Nerve deafness is not an uncommon disease. In my cases of deaf- 
ness there has been some involvement of the labyrinthine structures or 
auditory nerve in 27% of the cases examined. I think the reason for 
most authors putting the percentage of nerve deafness much lower than 
this is because of inexact methods of diagnosis. The above percentage is 
based upon the actual measurement of nerve force. See measurement 
of nerve force under non-suppurative otitis media above. 

A careful study of eases by the method of actual measurement of 
nerve force, shows that there are two distinct forms of nerve deafness. 
In one there is only a deficient function of the structures of the 
labyrinth, due perhaps to some perverted physiologic function, and this 
form we may call auditory nerve deficiency. The other form of nerve 
deafness, due probably to an actual degeneration of the nerve or its end 
organs in the labyrinth, may be properly known as auditory nerve degen- 
eration. 

Auditory Nerve Deficiency. — A study of our case reports shows 
that in 64% of the cases in which the nerve force was 16-30 or high- 
er (more than half) favorable results were obtained, provided that there 
was no complicating labyrinthine affection. These cases have been 
classed as "nerve deficiency" and the pathology as functional. A fa- 
vorable prognosis (64%) may be offered. 

Example of tuning fork findings : 

Fork 32 64 128 512 2048 4096 

B. C 18 20 20 20 10 

A. C T 50 60 60 '40 20 

In addition to the tuning fork findings the voice and watch test will 
be reduced to from one-tenth to two-thirds normal. The patient often 
complains of itching meati and dry nares. There are usually no signs 
or symptoms of labyrinthine affection. 



256 The Practice of Osteopathy 

Treatment. — The treatment consists of local treatment to the 
nasopharynx, tubes and meati as described under the treatment of 
chronic otitis media. Everything should be done to build up the patient's 
general health and improve the local nutrition. It is highly essential 
to search the entire system for sources of focal and general infection. 
Autointoxication from chronic gastrointestinal disease was found in 90% 
of our cases. Any treatment therefore that will restore normal gastro- 
intestinal function is indicated. Recently we have had some excellent 
results from colonic irrigation and the proper adjustment of diet in such 
cases. Any source of focal infection must of course receive proper atten- 
tion. 

The osteopathic corrective treatment consists largely of careful at- 
tention to lesions of the splanchnic area because of the importance of nor- 
mal digestion, metabolism and elimination. This is certainly a most im- 
portant part of the treatment and should never be neglected. Upper 
cervical and mandibular lesions have much to do with the local nutrition 
to the ear structures and these must not be neglected. The fact that we 
almost constantly find evidence of deficient nutrition to the meati and 
drums in this disease together with lesions of the mandible, suggests 
a local osteopathic cause. 

Auditory Nerve Degeneration. — In those cases in which there is 
a measureable deficiency of nerve function of less than half the normal 
we have found that very few respond to treatment. (See table above.) 
The cause has therefore been attributed to a structm-al pathology and the 
condition called auditory degeneration. 

Example Table: 

Fork 32 64 128 512 2048 4096 

B. C 10 12 8 5 2 

A. C S 20 25 15 7 5 

There is usually very marked impairment of hearing for voice and all 
other sounds. The Ingersoll watch may be heard five or ten inches, but 
usually not at all, and the whispered voice heard only a few inches or not 
at all. There are nearly always signs and symptoms of labyrinthine deaf- 
ness and evidence of tone islands. The deafness in these cases is usually 
progressive regardless of any treatment. 

In this disease there is nearly always an associated affection of the 
labyrinth as shown by the high forks. The fractions represented by the 
high forks will agree in proportion provided there is no labyrinthine 
involvement. 



The Practice of Osteopathy 257 

Our results in auditory nerve degeneration have been measurable 
improvement in only 2% of the cases treated. The prognosis is there- 
fore very poor and I believe we should always tell our patients frankly 
that there is almost no chance for improving their hearing in such cases. 
The treatment is the same as that given for nerve deficiency and because 
of the general good that may be had from treatment, that is, the im- 
provement of the general resistance, it is often well for the patient to have 
such treatment to stop the progress of further special sensory degenera- 
tion. 

It should always be our purpose to treat the patient rather than to 
treat some particular organ only and if this method is followed, our gen- 
eral results will surely be much higher. 

Diseases of the Nose 

Method of Examination. — For use in nasal examinations and 
treatment, a suitable chair with adjustable head rest is of much value be- 
cause if the patient is not comfortable and in a convenient position, the 
work is very difficult. A few instruments, such as the following, are very 
essential: A sterilizer for instruments, head mirror and reflecting lamp, 
nasal speculum, tongue depressor, tonsil pillar-retractor, a nasal pack- 
ing forceps and a few aluminum cotton applicators. These instruments 
are few and comparatively inexpensive, but are of more practical value 
than a Hfetime collection of electrical apparatus. Any physician can 
readily learn the use of these instruments and the methods of examina- 
tion by attending the clinical sessions of our conventions. Methods 
and technic of treatment, however, require much practice and exper- 
ience to develop efficiency. 

Acute Rhinitis 

This disease, commonly known as a "cold in the head" is one of the 
most common, and because of the complications which so commonly re- 
sult, a disease which really requires careful consideration. 

Etiology. — The predisposing cause is reduced resistance and indi- 
vidual susceptibility to air borne irritants and infective organisms. 

Direct exposure of some insufficiently protected part of the body such 
as the feet in cold, damp weather, exposure of some unprotected part 
of the body to draughts or exposure of the whole body to slightly reduced 
temperature for a considerable time, are the common causes. In cold 
weather, it is very important that the proper indoor humidity be main- 
tained, because the drying of the mucous membranes renders them sus- 



258 The Practice of Osteopathy 

ceptible to infection. This disease is not only contagious at times but 
may even become endemic from some specific and virulent organism. 

The comphcations which may and often do follow such infections are 
laryngitis, bronchitis, pneumonia, etc. and any one or more of the focal 
infections, such as sinuitis, tonsilhtis, or middle ear infection. A focal 
infection thus caused may become chronic and render the patient con- 
stantly susceptible to head colds. In fact in those persons who suffer from 
chronic head colds, there may nearly always be found some focal infec- 
tion, such as the above named, and it is often impossible to get permanent 
rehef until such sources of focal infection have been properly treated. 

The influence of gross structural lesions, osteopathic lesions of the 
cer\dcal and upper thoracic region, vertebrae and ribs must not be over- 
looked because they exert a powerful influence upon the blood supply, 
particularly the venous and lymphatic drainage and upon the autonomic 
nervous mechanism, which regulates the physiologic control of such func- 
tions. 

Gross structural abnormalities of the intranasal chambers, such as 
deflected septum, enlarged turbinates or cellular turbinates, which cause 
deficient or abnormal breathing space, may cause and maintain head colds. 

Diagnosis. — The diagnosis is usually easy. Nasal congestion 
with the usual '' stuffy" feeling of the head, sneezing, headache, etc. are 
well known symptoms. On direct examination the nares are congested, 
there is a watery discharge and all of the membranes of the nasopharyn- 
geal tract are congested. 

Treatment. — If there is ever a demand for good, thorough and 
specific osteopathic work, certainly it is demanded in such cases. I 
am an advocate of thorough, deep relaxing treatment followed by spe- 
cific adjustment in such cases. 

Complete rest in bed with hght diet and careful attention to the ehm- 
ination are verj^ essential. Perhaps the most difficult problem is to con- 
vince the patient that a head cold is really a serious disease and demands 
thorough and prompt treatment. Every ear, nose and throat speciahst 
has had ample opportunity to know that most of the really serious com- 
plications of the head and neck result from the lack of prompt and proper 
attention to head colds. 

The local treatm.ent consists of irrigation of the nasopharynx fol- 
lowed by oil spray to protect from further irritation and the mainten- 
ance of proper drainage from the sinuses and middle ears. I am not 
an advocate of the so-called "antiseptic sprays" because they neither 
destroy bacteria sufficiently to be effective nor do they maintain drainage. 



The Practice of Osteopathy 259 

In all cases, the physician should be ever watchful for the complica- 
tions and should not hesitate to call consultation of a specialist when 
such symptoms develop. 

Purulent Rhinitis 

Persistent inflammations of the nasal membranes are usually of a 
purulent nature or at least have had such a cause in the beginning. 

Etiology. — Purulent rhinitis may be a result of an unsuccessfully 
treated infection of the nose or throat following some disease of child- 
hood or early life. It may be due to infection at birth. Commonly 
there is a subacute or chronic sinus infection that maintains the infection 
of the nasal mucosa. Polyps, enlarged or cellular turbinates, adenoids or 
adhesions in the epipharynx, often retain the secretions and cause chronic 
rhinitis. In many cases I have found that osteopathic lesions of the cer- 
vical or upper thoracic region are effective causes of chronic rhinitis. 

The Pathology consists of hyperemia, hypertrophy and exfoliation 
of the cellular membrane. The turbinates and all membranes become 
enlarged and thickened and the breathing space is usually greatly de- 
creased. 

The Symptoms are nasal obstruction, and mucous or mucopuru- 
lent discharge with usually hypersensitiveness, which causes sneezing 
and other symptoms common to "head colds." 

Treatment. — The same treatment as given above for acute rhinitis 
applies here. A thorough examination should be made for all of the 
various causes given above and the proper corrective treatment given 
for any or all such causes. 

Chronic Hypertrophic Rhinitis 

Etiology. — Chronic rhinitis is usually a result of an infective rhi- 
nitis and has for its cause any one or more of the various causes given 
above under purulent rhinitis. 

Pathology. — The pathology in chronic rhinitis varies with the cause, 
but is usually characterized by a series of changes beginning with infec- 
tion and hyperemia and followed by an actual and usually marked hyper- 
trophy of the interstitial tissue. The posterior ends of thei nferior or, 
less often, the middle turbinates are usually enlarged and extend back- 
ward into the pharynx. 

The Symptoms aie much the same as in purulent rhinitis, 
except that the purulent discharge is often not present. These cases 
usually suffer from chronic head colds, headaches and persistent nasal 



260 The Practice of Osteopathy 

obstruction. The-senses of smell and taste are usually impaired and there 
is a nasal twang to the voice. 

Treatment. — In these cases, it is common to find osteopathic causes 
which prevent proper drainage from the head and neck and this is im- 
portant because, if all the local causes are properly corrected, this is not 
sufficient to effect a cure. 

Surgical treatment for the removal of polyps, sj^nechia, adenoids, 
adhesions, correction of septum, or hypertrophied or cellular middle tm-- 
binates is often essential and certainly infected sinuses must be properly 
drained. We have had cases in which root abscesses seemed to be ac- 
tive causes, but it must not be thought that surgery and sm-gery alone 
is hkely to cure chronic rhinitis, and I want to caution against the whole- 
sale removal of turbinates for such conditions. The mere fact that the 
turbinates are enlarged is not sufficient reason for their removal. There 
has been a cause for this enlargement and turbinotomy or turbinectomy 
does not remove this cause. Cautery is worse, because it seldom ac- 
comphshes more than very temporary results and often leaves the mem- 
branes worse than before. Cautery destroys mucous membrane, leaving 
a dry and easily irritated surface which is often impossible to normahze. 

The proper surgery, carefully done, followed by efficient osteopathic 
corrective work and thorough irrigation of the nasopharyngeal tract 
with the necessary oil spray protection after irrigation, will constitute 
efficient treatment. Treatment, thorough and long continued, will in 
due time restore nutrition, drainage and normal reflex nerve control to 
the tissues. Treatment after surgery is essential. 

Intranasal Treatment. — Many cases are caused by the retention 
of secretions under the turbinates and in the superior vault. In all 
cases, therefore, it is essential to thoroughly free all possible retention 
cavities by means of a small cotton-wound probe before irrigation. 
The intranasal membranes are adrenahzed and anesthetized and 
a thorough examination >is made using a good reflecting lamp, nasal 
speculum and cotton tipped probe. Every part of the intranasal re- 
gion is inspected for sources of purulent discharge, mucus collections, 
synechia and for hypersensitive areas. The probe is curved at the end 
and passed under each turbinate and drawn forward and backward with 
considerable pressure to insure that any collection of foreign matter is 
thoroughly lemoved. Every part of. the intranasal region should be 
thoroughly treated in this way. The hiatus semilunaris must be kept 
well open to permit free antrum drainage and all other sinus openings 
should be kept free from any obstruction that may block the drainage. 



The Peactice of Osteopathy 261 

This particular technic requires great care and practice, but it is very 
effective and so commonly we have found that this work thoroughly 
done will reduce much and in some cases all of the turbinate hypertro- 
phy rendering surgery unnecessary. 

Atrophic Rhinitis 

As the term suggests, this disease is just the opposite from hyper- 
trophic rhinitis in that the membranes are shrunken, the nares are wide 
open and usually the membranes are coated with a mucopurulent dis- 
charge, accompanied by a bad ordor. It is a chronic disease and progres- 
sive in nature. 

Etiology. — Deficient nutrition, systemic or local, or some degener- 
ative infective process constitutes the cause. Some cases may be traced 
to syphiHs, but this is certainly not always the cause. Chronic sinuitis, 
the cause of which is some virulent infection, is often the cause. Too 
much or incorrect surgery and cautery is certainly a cause in many cases. 

Pathology. — The marked atrophic appearance, the retracted tur- 
binates, the excessive purulent or mucopurulent foul discharge are 
characteristic and diagnostic. 

The tissues underlying the mucous membranes are shrunken, and at- 
rophic and this tissue has usually been replaced, sometimes almost com- 
pletely, by connective tissue, and thus the blood supply is markedly 
deficient. 

Treatment. — In chronic cases, those in which the atrophy is well 
progressed, there is no hope of restoration to normal conditions, but I 
l^elieve that the progress of practically every case can be stopped and that, 
in most cases, a permanent cure can be effected under proper treatment. 

Every ijossible source of focal infection, such as sinuitis, pharyn- 
gitis, tonsillitis, etc. should receive proper attention promptly. After 
this has been done and sufficient time allowed for normalization, a blood 
count may reveal some other source of focal or general infection, which 
may be reducing the general resistance. 

Auto-intoxication from some gastro-intestinal affection is commonly 
a cause and must receive proper attention. The general health of the pa- 
tient must be restored and maintained. 

Thorough osteopathic treatment must be given for any cause of low- 
ered nutrition, local or general. The failure, I believe, in medical practice 
(They admit failure in this disease) is due to the lack of attention to the 
restoration of normal nutrition. Why drain a sinus and leave an atlas 
or upper thoracic lesion which decreases the local nutrition and leaves 
these membranes susceptible to further infection? 



262 The Practice of Osteopathy 

Before and after surgical drainage, irrigation of the nasopharjTi- 
geal tract. Thorough irrigation to cleanse every part. Hot irrigation 
(one gallon of salt mixture solution, salt 3 parts, borax 2 parts, and soda 
1 part, a tablespoonful to the gallon at 118°F. to 123^F.) to cleanse, to 
free all parts from infection and to restore blood supply to the affected 
parts. Frequent irrigation, daily for a sufficient time to thoroughly 
sterihze and restore circulation. After each irrigation, an oil spray (any 
non-irritating petroleum oil) is applied freely to protect the membranes 
from irritation and further infection. 

Before each irrigation a thorough probe treatment, as described 
under hypertrophic rhinitis, should be given that the membranes may 
be thoroughly freed from all retained secretions. 

After the membranes are once clean, the sinuses free from infection 
and the blood supply reestablished, the treatment may be reduced in fre- 
quency to three times weekly, but the treatment must be continued for 
months or even years to effect a permanent cure. The patient can be 
taught to do his own irrigation after the disease is well under control. 
All irritating sprays, chemical cauteries, etc. must be avoided. The so- 
called "antiseptic sprays" do harm by irritating the membranes and cer- 
tainly do no good, because they do not cleanse the parts. They only serve 
to deodorize, but actually accompHsh nothing in the way of cure. It 
has been my experience that iodine and the silver salts in any of their 
various preparations are not efficient but that they actually do harm. 
My experience indicates that practically every case can be cured if the 
proper treat aent is given for sufficient ti ae. 

Pharmacodynamics 

If I may be pardoned for discussing things pharmacological in a text 
on practice, I want to urge that chemicals as such, are usually a failure 
in treatment. My results from various series of experimental work 
both laboratory and chnical, show quite conclusively that there are very 
few, if any, chemical substances that have actual value by virtue of their 
chemical properties alone. There are, however, cases in which chemical 
agents may be used to advantage to obtain desirable physical results and 
physiologic reactions. 

The salt mixture mentioned above increases the solvent power of the 
water for mucus, pus, and other collected material and it also renders the 
water less irritating to the mucous membranes. Other than this, it 
has no value so far as I know. This solution is certainly not antiseptic 
or germicidal, further than that cleanliness may be considered an antisep- 
tic procedure. 



The Practice of Osteopathy 263 

The phenol-glycerine (10% phenol and 90% glycerine) which we have 
recommended, is somewhat germicidal, non-irritating, except to the 
nasal mucosa, is a protectant to inflamed membranes in some instances 
and is also somewhat hygroscopic. These virtues to the Umited extent 
that they may be of advantage, depend chiefly upon physical quahties. 

Adrenalin in high dilutions (1 to 5000 to 1 to 10,000) is of value in 
retracting the erectile tissues of the nares for puproses of examination 
and for obtaining better drainage, etc. It also constricts the small 
blood vessels and thus reduces the chances for hemorrhage or absorp- 
tion of narcotic drugs which may necessarily be used as local anesthetics. 
The effects of adrenaHn are very temporary and it is, therefore, of Httle 
value in treatment. 

Following irrigation I have used the petroleum oils (Hquid petrola- 
tum) to advantage as a protection to the mucous membrane. One half 
gram each of menthol and camphor and two or three drops of cinnamon 
oil to the pint of this oil, is readily dissolved and produces a pleasant, 
soothing effect to inflamed membranes, but further than this, the add- 
ed substances have no particular value. The above named chemical 
agents constitute, except in rare instances, my stock of "drugs" for 
treatment purposes. 

Hyperesthetic Rhinitis — Hay Fever 

There is perhaps no disease in which there has been more speculation 
concerning the etiology than in hay fever, and while osteopathy has ac- 
complished a wonderful advance in the treatment of this disease, I am 
not sure that the cause or causes are yet thoroughly understood. 

Etiology. — The theoretic causes of this disease may be expressed in 
the various names which have been given to it as follows: The term 
Hay Fever suggests that it is a febrile condition caused by hay pollen 
irritation. Peach cold. Rose cold. Rose fever. Rose catarrh. Rye fever 
and Ragweed fever suggest similar specific causes. Idiosyncratic coryza 
means nothing and this probably expresses what the theorists know about 
its cause better than any other name. Hysteric rhinitis suggests a prob- 
able psychic cause, which certainly does exist in some cases. If I may 
be pardoned, and I know I never will be, let me suggest just one more 
name — "Respiratory Reflex Ineflaciency. " 

Intoxications. — Autointoxication from focal infections or from 
gastro-intestinal perversions certainly have an important influence 
either directly or as predisposing factors and should always be carefully 
considered in treatment. 



264 The Practice of Osteopathy 

Osteopathic Lesions. — Osteopathic lesions, such as interosseous, 
muscular and Hgamentous, seem to function as predisposing causes by 
their general effects upon the sj^stem. It seems probable that their ef- 
fects upon the organs of metaboHsm and elimination are of greater impor- 
tance than any direct or specific effect in causing the immediate symptoms. 
In practically all cases lesions of the upper thoracic vertebrae and ribs 
and of the cervical region are present. It is my opinion that such lesions 
are more often secondary than primary. 

Respiratory Reflex Inefficiency. — Measurement of nerve force 
in these cases shows that none are really possessed with "an excess of 
nerve force, " but that practically all vary from two-thirds to four-fifths 
normal, showing that probably all cases are deficient in nerve force. 

This instabiUty of the nervous system can be explained, I believe, 
in the theory of peripheral reflex insufficiency. As evidence of this the 
following facts may be cited: 

1. It is known that peripheral irritation of almost any nature, to 
the mucous membranes of the nasopharyngeal tract, will excite an attack 
in susceptible individuals. 

2. That any treatment which tends to increase the resistance of 
these membranes will prevent or reheve an attack. 

3. That peripheral inhibition to these surfaces will temporarily 
relieve an attack. 

4. That complete normahzation of these membranes will make 
the patient resistive to the so-called specific irritants, such as pollen, 
dust, etc. 

5. That the mucous membranes of the entire respiratory and gas- 
tro-intestinal tract react to irritants to bring about "the hay fever state" 
and that any treatment which tends to normalize these membranes, ren- 
ders the patient more resistive to hay fever attacks. 

Exciting Causes. — There is no doubt that various air-borne irri- 
tants, such as pollen, dust, chemical fumes, emanations from animals, 
etc., act as exciting causes of acute attacks, and j^et there are cases that 
develop acute attacks out of season or at a time when it seems that there 
could be no air-borne irritation. From evidence which will be offered 
later (see prognosis) I am led to beUeve that probably all susceptible 
cases can be made entirely resistive to the air-borne irritants. 

Patliology 

Functional Patliology. — Certainly in this disease there is ample 
evidence of marked perversions of function or functional pathology. 



The Practice of Osteopathy 265 

Kyle believes that in many cases the cause of local irritation lies in 
"some chemical change in the constituents of the mucus-secreting 
glands, " and "it is a well known fact that in many cases of hay fever the 
irritation is not hmited to the nasal mucous membrane. The eyes and 
mucous membrane of the stomach and bladder, and even the intestines 
may be markedly irritated." 

These chemical changes in the secretion of the mucous membranes, 
together with the excess of uric acid would seem to point either to a general 
perversion of the secretory mechanism or to a deficient elimination, or 
to both. The periodic occurrence may be accounted for by assuming 
that the systemic strain is sufficient to initiate the symptoms. The 
fact that the attack is actually delayed or hastened in susceptible in- 
dividuals by the late or early beginning of hot weather, and that these 
cases get rehef by going to a more moderate chmate is further evidence 
of this. 

Again we are reminded of Dr. Still's teaching, that the body main- 
tains its own chemical laboratory which adjusts or tends to adjust its 
work to the needs of that body, but under abnormal strain this adjustive 
mechanism may fail to meet all of the demands of function. It seems 
here that the osteopathic concept may easily include all environmental 
causes as well as internal causes in the predisposition to deficient func- 
tion or disease. 

Structural Pathology. — During the attack there is a general catar- 
rhal inflammation of all nasopharyngeal membranes, accompanied by a 
watery discharge and marked swelling of the turbinates. Sensitive 
areas may be found on the middle turbinate and opposite wall of the 
septum. Probably it is this hypersusceptibility to irritation that causes 
the attack from the air-borne irritants. 

The pseudo-membrane which may be found covering a part or all 
of the mucous membranes of the nares probably results from this irrita- 
tion and is formed for the purpose of protection. 

Clinical Types. — CHnically, three rather indefinite types of hay 
fever may be recognized, viz.: Vernal, those cases which have their at- 
tack sometime during May, June or July; Autumnal, in which the attack 
occurs in August or September and usually lasts until the beginning of 
cold weather, and an indefinite or pseudo form occurring at any time of 
the year, with no characteristic attack, as in the other forms, but with 
indefinite s^^mptoms resembhng hay fever. 

Symptoms and Diagnosis. — Patients usually go to the physician 
self diagnosed. The characteristic sneezing, the watery discharge from 



266 The Practice of Osteopathy 

the nose, and the irritation of all membranes of the naso-pharynx and 
conjunctiva will serve to make a diagnosis in most cases. Direct exam- 
ination will reveal the nasal congestion and other characteristic pathology 
as described above. 

Termination. — Most cases of the autumnal form, unless successful- 
ly treated, continue with equal or increased severity until after the first 
or second frost, when they usually terminate in asthma, bronchitis or 
sinuitis, which lasts for several weeks or months. Each year the at- 
tack lasts longer and is nore severe and the asthma occurs earlier and 
is more severe. 

Treatment 

Intranasal Surgery. — Intranasal abnormalities, such as deflected 
septum, spurs on the septum, hypertrophied turbinates, polypi, etc., 
which materially reduce the breathing space, usually demand surgery. 
Nasal surgery, carefully and properly done, is always a great aid and 
often absolutely essential to the successful treatment of hay fever and 
asthma, but nasal surgery carelessly done frequently does more harm 
than good. 

The correction of a deflected septum or the removal of a spur on the 
septum by submucous operation often aids materially in the prevention 
of pressure irritation, increases the breathing space and normalizes drain- 
age from the sinuses. 

Surgery is therefore very essential in many cases of hay fever, but 
surgery is never the all essential part of the treatment, because if the 
proper after treatment is not given, the surgery alone will seldom result 
in either temporary relief or cure. 

Focal Infection. — The importance of focal infection of the sinuses, 
tonsils, teeth and occasionally other parts, such as the nasal cavities, 
epipharynx, middle ear and mastoid cavities cannot be overestimated. 
Such conditions may be effective in causing hay fever, by causing direct 
infection of the membranes of the naso-pharyngeal tract or by auto- 
intoxication. 

Digital Surgery, for the removal of adhesions in the posterior nares 
and pharynx, is in my opinion, very essential, and this work should be 
done thoroughly. Massage of the soft palate or pharyngeal walls is of 
no particular value. All adhesions and adenoid tissue must be removed 
because this removes an effective source of constant irritation and focal 
infection and tends to normalize the direct and reflex nerve mechanism. 

The practice of the radical intranasal technique as originated by 



The Practice of Osteopathy 267 

J. D. Edwards, D. 0., is indicated, I beKeve, in some cases in which the 
crushing of cellular middle turbinates, or the breaking of adhesions is 
indicated, but I am not yet ready to accept this theory of "curetting" 
the mucous membrane by radical digital technique. The fracture of 
the turbinates is not necessarily a bad technique provided they are prop- 
erly readjusted as Dr. Edwards does it, but to fracture and not readjust 
is a dangerous practice. The efficiency and safety of any method depends 
upon the operator's definite knowledge of what needs to be accompHshed 
and how it is to be done. 

There are contraindications to digital, as well as any other kind of 
nasopharjmgeal surgery, such as: (1) Acute infection of any part of the 
nasopharyngeal tract; (2) evidence of sinus involvement; (3) septal 
deflections, spurs and hypertropKied turbinates, which would not permit 
such work without undue trauma. 

There are certain other precautions such as thorough cleanhness 
of the parts to be treated; aspiration of the sinuses before and afterward, 
and the use of a finger of sufficient size which will not produce undue trau- 
ma. In my opinion very few doctors have such fingers. 

Failure in accomplishing results is due to three things, viz., (1) In- 
sufficient knowledge of diagnosis and prognosis; (2) insufficient knowl- 
edge of what should be accompHshed and the technique of doing it, and 
(3) the necessary additional or supportive treatment. 

It is a great mistake to think that the removal of adhesions in the 
pharynx or nares is sufficient, because if this is not followed by the proper 
supportive treatment, no results or even bad results will frequently 
occur. This treatment is not a massage in any sense, but a definite 
operative procedure and requires as much care and skill as the removal 
of adenoids or tonsils. 

Space will not permit an explanation of the digital technique and the 
radical treatment should not be attempted without some definite knowl- 
edge of the methods and technique. 

Intranasal Treatment. — The intranasal method of treatment as 
explained above under hypertrophic rhinitis is very effective and if care- 
fully and thoroughly done is in most cases just as efficient as intranasal 
digital surgery. This treatment followed by irrigation and oil spray 
and nasal pacldng will be found effective in most cases if the treatment 
is properly don(>. 

Nasal Packing. — Thorough packing of the nasal cavities after all 
sources of focal infection have been removed and after thorough cleans- 



268 The Practice of Osteopathy 

ing has been done, by means of long strips of absorbent cotton is effective 
in reducing the swelling and iriitation. 

The Radical Packing Method. — This method can be done best 
in a hospital. The nares are prepared as for surgical operation, by com- 
plete retraction of all erectile tissue, thorough cleansing by irrigation and 
the apphcation of a local anesthetic. Anesthesia need not be complete. 
A careful examination is then made for any sjmechia, or focal infections. 
Packing should never be done until the doctor is sure there is no sinus 
involvement. The entire nasal cavity is then packed very firmly with 
sterile gauze. This is best done by means of a special packing instru- 
ment or long nasal packing forceps, using narrow gauze contained in 
tubes. In some cases the nasal ca\aty is lubricated before packing. 

The packing should be done early in the morning and removed just 
before bed-time, so that the patient may sleep. This treatment is re- 
peated daily until all signs and sjTuptoms of nasal irritation are gone and 
then replaced by irrigation and oil spray. 

If tliis treatment is properly done, there will be a complete sloughing 
of the pseudo-membrane followed by a restoration of normal and resis- 
tive tissue. The results of our two years' experience (we have tried this 
on only a few patients each year) are very encouraging. Relief fi;om 
the sj^Tiptoms are very prompt and seemingly more permanent than from 
other methods. 

Treatment of Auto-lntoxication. — All sources of focal infection 
are thoroughly treated. Sinus infection is very common and must re- 
ceive proper attention before any other treatment can be effective. 

Our experience shows that many cases have auto-intoxication of 
gastro-intestinal origin. The hospital care of such cases makes possible 
the thorough cleansing of the colon by irrigation and the reestabhshment 
of an acid producing flora which seems to prevent fermentation. 

Osteopathic Corrective Worl<. — Thoroughness of treatment for 
the removal of all causes is the secret of success. To successfully remove 
the immediate sources of auto-intoxication by treating a sinus infection 
or by thoroughly freeing the colon from fermentation products means 
only temporary results if the underlying causes are not corrected. A 
thorough osteopathic examination is necessary to determine such causes 
and certainly such treatment should not be neglected. 

Correction of all cervical and upper thoracic lesions and particularly 
the clavicles and ribs is important. These lesions seem to be the result 
rather than the cause, but normal respiratory functions seemingly cannot 
be maintained unless such treatment is done. 



The Practice of Osteopathy 269 



Sinuitis 



I 



Acute or chronic inflammatory disease of the nasal accessory si- 
nuses with or without suppuration is more common, I believe, and is re- 
sponsible for more complications and chronic affections of the nose and 
throat than is generally known. 

Etiology. — The cause in most cases hes in unsuccessfully treated 
acute infections involving the nose and throat. Abnormalities of the 
nasal respiratory passages such as deflected septum, enlarged or cellular 
turbinates, adhesions resulting from cautery or careless surgery, causing 
deficient drainage, constitute the local causes. Underlying some of these 
direct causes, lesions of the cervical region which impair the nutrition 
to and drainage from the head are to be considered. 

Symptoms and Diagnosis. — Acute or chronic headaches and neu- 
ralgic pains of the head are common symptoms. Acute sinuitis of the 
frontal sinuses is accompanied by marked and persistent frontal headache 
and pain in the eyes. In infections of the maxillary sinus there is usually 
pain over the affected part, but there is often referred pain to other parts 
of the head. Sphenoidal sinuitis usually causes general headache with 
no definite location. 

By direct examination of the nasal cavities a purulent or mucopur- 
ulent discharge may be seen and the source determined. In many cases, 
however, the pus may be retained or insufficient in amount to detect by 
direct examination. 

Transillumination in a dark room by means of a good transillum- 
inator will usually show a darkened area over the affected part. The 
average battery equipments commonly sold for this purpose are of httle 
value. The X-ray plate when properly done, is more dependable than 
the transilluminator. 

In some cases, all of these methods fail to locate the affected sinus 
and the cause can be found only by opening into the sinuses, aspirating 
with a catheter and making microscopic examination of the aspirated 
material. The microscope is indispensible for this work. Every sus- 
picious discharge should be stained until pus is found and except in wel 1 
defined cases, this is the only practical method of positive diagnosis. 

Treatment. — Local treatment of the nasal cavities by retracting 
the turbinates and irrigation will be successful in many cases, but unless 
there is a large normal opening the pus will not drain sufficiently and 
probe treatment is required. In acute cases in which the pain is marked, 
osteopathic treatment of the cervical region, deep relaxation of the sub- 



270 The Practice of Osteopathy 

maxillary structures and the application of heat over the affected part, 
together with the local nasal treatment should be given, but if this does 
not relieve the pain within twenty-four hours, the sinus should be opened 
and thoroughly drained. If efficient drainage is not established early 
the symptoms will usually increase until the pain is almost unbearable 
and serious complications may result. 

In practically every case of acute sinuitis, I beheve it is best to make 
a good, free opening into the affected sinus first and secure complete drain- 
age by catheter aspiration. If this is properly done every case will 
recover much more quickly and without comphcations or danger of 
chronic infection. 

Non-Suppurative Sinuitis 

Cases of non-suppurative sinus involvement are not at all uncommon. 
The so-called "Vacuum sinuitis" which results from a closure of the 
normal opening, resulting in inflammation without pus formation, is re- 
sponsible for many of the complicated cases of referred pain, which are 
so often improperly diagnosed. Chronic headaches and the various 
symptoms of fifth nerve affections, the neuralgias of the head, are fre- 
quently caused by non-suppurative sinus involvement. 

Treatment. — The treatment consists of estabhshing good drainage 
and proper ventilation of the affected sinus or sinuses followed by thor- 
ough intranasal treatment as explained above. The osteopathic correc- 
tive work must not be neglected. 

Sypliilis of the Nose 

In osteopathic practice syphilis is not a common disease. The oc- 
currence of syphilis of the nose is still more rare but certainly should be 
recognized. 

Diagnosis. — The local lesions of the nose are of two types, those of 
acquired syphihs and of congenital syphilis. 

There are three characteristic manifestations of acquired sypliihs as 
follows. The primary lesion or hard chancre is a firm, indurated ulcer- 
ated mass with only slight discharge. Chancre of the nose is exceedingly 
rare. In secondary syphilis there is the mucous patch, the result of mu- 
cous membrane necrosis. In tertiary syphihs the local lesion is the gum- 
ma or more commonly, the ulceration left from necrosis of the gum- 
ma. These lesions may appear from a few to many years after the ini- 
tial infection, but they never follow immediately. The lesions may ap- 
pear on almost any part of the intranasal structures. They resemble 



The Practice of Osteopathy 271 

the lesions of atrophic rhinitis but in atrophic rhinitis there is never the 
extent of destruction that so frequently results from tertiary syphihs. 

Treatment. — It has been my practice to refer all suspected cases 
to Dr. F. J. Stewart for differential diagnosis and treatment and his 
method of the use of salvarsan has proven efficient. 

Epistaxis — Nose Bleed 

The causes of nose bleed may be divided into two general groups, 
local and constitutional. The first group consists of trauma directly to 
the nose either external or internal, from nasal operations and other caus- 
es. The presence of a cluster of thin-walled veins on the anterior part 
of the septum wliich readily rupture from shght cause, constitutes per- 
haps the most common cause of nose bleed. The ulcers of atrophic rhi- 
nitis or syphihs occasionally cause bleeding. Mahgnant growths of the 
nose may cause frequent and profuse hemorrhage. The constitutional 
causes of epistaxis are, the acute fevers, cardiac and arterial diseases, 
which cause excessive tension; and cases of altered composition of the 
blood such as the anemias, malaria, purpura, chlorosis, hemophiUa, etc. 

Diagnosis. — Direct examination of the nose will usually reveal the 
cause. If there are no signs of trauma or rupture of the anterior group 
of vessels and the bleeding does not respond quickly to packing of the 
affected side, there is either a rupture of a large vessel; which requires 
long continued pacldng, or it belongs to the class of constitutional disease. 

If there is evidence of some necrotic disease of the nose or if there 
are areas of exposed bone or cartilage from careless surgery, these may 
usually be seen and the point of bleeding located. 

Treatment. — Cold appfications, irrigation of the nares with cold 
normal salt solution and the application of an absorbent cotton or gauze 
pack is usually sufficient to stop the average case of epistaxis from any 
cause. The direct application of cold to the lower cervical region will 
cause capillary restriction. 

There are many cases in which the membranes of the nose have lost 
their tone due to various irritants or from deficient nutrition to the parts. 
These are cases of a wholly different type from that of the well known 
necrotic diseases such as atrophic rhinitis and syphilis. Hay fever is a 
result of such a cause. The treatment in such cases consists of removing 
any local causes or osteopathic lesions and then normalizing the resis- 
tance of the membranes by the methods described under the treatment 
for hay fever. 



272 The Practice of Osteopathy 

The treatment for those cases of epistaxis due to constitutional dis- 
ease depends wholly upon the causative factors and the proper treat- 
ment of these. Any local treatment in such cases will be expected to 
produce only temporary results. 

Diseases of the Nasopharynx 

The nasopharynx may be the location of acute or chronic inflamma- 
tions, neoplasms, malignant or nonmalignant, processes of atrophy or 
hypertrophy, adhesions, etc. It is important to remember that the naso- 
pharynx admits the Eustachian tubes and supports four superficially 
located gangha of the fifth nerve. 

Acute Nasopharyngitis.— Acute inflammatory pi'ocesses of this 
region may result from rhinitis, infections of the lower pharynx, focal in- 
fections of these parts or from direct involvement of its own structures. 

The symptoms are post nasal tenderness and mucus dropping. 
Some patients experience the sensation of a foreign body in that location. 
The thick, adherent collections of mucus are difficult to dislodge and some- 
times are so persistent that they cause nausea. There is usually occlu- 
sion of the Eustachian tubes, resulting in partial deafness, tinnitus and 
often dizziness. 

The Treatment consists of thorough cleanliness by irrigation 
and osteopathic corrective work to the cervical region. It is also es- 
sential to keep the anterior neck structures particularly those of the 
submaxillary region, thoroughly relaxed to maintain efficient drainage. 

Chronic- Nasopharyngitis 

This is one of most common diseases of the nasopharyngeal tract, 
causative of many complications and yet perhaps the least recognized in 
proportion to its significance. The frequent occurrence of adhesions 
of the pharyngeal fossae, hypertrophied membranes, enlarged spongy 
extensions of the inferior and middle turbinates (the posterior turbinate 
bodies) occlusion of the orifice of the Eustachian tubes and chronic, ex- 
cessive secretion of thick mucus all show that this disease has either gone 
unrecognized or at least has not received proper treatment. 

Treatment. — Complete surgical removal of all abnormal growths, 
adhesions, etc. as described under the treatment of chronic non-suppur- 
ative otitis media and this followed by thorough irrigation and other meth- 
ods of local treatment described above are efficient. The successful treat- 
ment of this disease requires time. There has been a partial or, in some 
cases, almost a complete loss of the normal fuctions of the nerve reflex 



The Practice of Osteopathy 273 

mechanism of these parts, peripheral reflex inefficiency and this must be 
restored. Efficient and long continued treatment of the lesions commonly 
found in the cervical and upper thoracic regions will do much to restore 
these normal functions, but this alone without the surgical treatment 
ill never effect a permanent cure. Neither will the surgery and local 
treatment alone effect a cure. The whole treatment is required. 

Adenoids 

Adenoids are the hypertrophied lymphoid tissue of the nasopharynx. 
They occur commonly in children, as a result of acute inflammations. 
Possibly the suckling process of the child produces a partial vacuum of 
the epipharynx and thus causes excessive blood supply to the part and 
therefore excessive growth of these soft tissues. 

Adenoids, however, are not confined to children but frequently occur 
in adults. In all cases they are a source of much annoyance and often 
the cause of acute and chronic disease. 

Symptoms and Diagnosis. — Mouth breathing, head colds, partial 
deafness, etc. are the common symptoms. The flattened nose, the high 
arch of the hard palate and the stupid appearance of the face are diagnos- 
tic. By direct palpation to the nasopharynx the nature and extent of 
the adenoid mass can be determined and this is the best method of diag- 
nosis. 

Treatment. — Many methods of non-surgical treatment have been 
employed, but there is nothing as satisfactory as complete surgical re- 
moval. Adenoid tissue has no known function different from that of 
other lymphoid tissue and there is always sufficient to perform any neces- 
sary function without excess of adenoid growth. The excessive adenoid 
growth is in every case a detriment to normal development, because it 
impairs nasal respiration and usually causes chronic nasopharyngitis 
and thus reduces resistance against all diseases of childhood. There is 
therefore, no excuse, much less a reason, why excessive adenoid growths 
should not be removed surgically, provided it is properly and thorough- 
ly done. 

The operation for removing adenoids requires in cliildren, a general 
anesthetic. In adults, a local anesthetic is used by some operators. 
I have found it best to first break the adenoid aass away from the side 
walls of the pharynx digitally. A LaForce or Gradle adenotome is then 
used to remove the adenoid mass. If either of these instruments is 
properly used it will always remove the greater part of the adenoid 
mass without undue trauma or injury to any of the pharyngeal structures. 



274 The Practice of Osteopathy 

Cnrets should never be used because they ahnost never remove the aden- 
oid mass properly, but they usually do injure the pharynx. Many 
cases of pharjmgeal adhesions. Eustachian tube occlusion and naso- 
pharyngitis result from direct injury caused by curets. 

After the adenoid mass has been removed the finger is inserted into 
the pharynx and any adenoid growths in the posterior naresare removed. 
The pharyngeal fossae are also thoroughly freed from adenoid tissue and 
adhesions and the orifices of the pharyngeal portions of the tubes are 
gently dilated. This method insm-es complete removal of all excessive 
adenoid tissue, and normal functions of the nasopharynx. Adenoids thus 
removed do not return. 

After the surgical work has been completed the nasopharjTigeal 
tract should be thoroughly irrigated with hot salt mixture solution. 
This thoroughly cleanses the membranes, hastens healing, prevents hem- 
orrhage and avoids post-operative infection. Irrigation of the naso- 
pharynx should be continued for some days or until all evidences of in- 
flammation have ceased. The pharynx should then be examined to be 
sure that no adhesions have developed from inflammation, but if the 
operation is carefully done, complications will never result. 

Diseases of the Oropharynx 
Acute Pharyngitis 

Acute inflammations of the pharynx alone or in common with in- 
flammations of other parts of the nasopharyngeal tract are common. 
This disease is most common as a result of the acute infections affecting 
the nose and throat. 

Etiology. — The predisposing causes are focal infections of the 
nasopharynx, such as tonsilhtis, sim,itis, etc. Deficient nutrition or 
anemia of the pharynx or systemic anemia are common causes. Lesions 
of the cervical, upper thoracic and hyoid are common predisposing causes. 
Undue exposm*e of the neck in susceptible persons or too much or too 
tight clothing about the neck ma}^ also predispose to inflammations of 
the pharynx. 

The exciting causes are the acute infections, colds and focal infec- 
tions. Perhaps the most common exciting cause is tonsillitis, acute or 
chronic. 

Symptoms and Diagnosis. — The characteristic dr\Tiess of the 
pharj^nx, pain and persistent coughing are diagnostic. Upon direct 
examination, the reddened, swollen appearance of the pharynx and pos- 
terior pillars can be seen. 



I 



The Peactice of Osteopathy 275 

Treatment. — The treatment should be general and local and 
should be determined by the causes and conditions present. This dis- 
ease is usually an acute infection and Kke other acute infections, the usual 
systemic treatment should be applied. 

The local treatment consists of throrough cleansing of the naso- 
pharynx (by irrigation if the patient can permit) and the frequent (or 
occasional as required) use of some gargle until the inflammation has sub- 
sided. Any cleansing nonirritative solution may be used for a gargle. 
Equal parts of peroxide, alcohol and glycerine, a tablespoonful to a half 
glass of very warm water or ten to fifteen drops of phenol-glycerine to 
a half glass of warm water will make a good cleansing gargle. 

The osteopathic treatment consists of corrective work to the cer- 
vical, upper thoracic and hyoid and thorough relaxation of the submaxil- 
lary musculature to obtain good venous and Ijnnphatic drainage. If 
sufficient care be taken to avoid trauma, digital stretching of the soft 
palate and pharvngeal muscles by the use of the finger internally, is very 
efficacious. 

Chronic Pharyngitis 

Chronic pharyngitis may be hypertrophic, atrophic or granular. 
In hypertrophic pharyngitis the pathologic changes have passed beyond 
the stage of hyperemia and there is always hypertrophy or hyperplasia, 
usually the latter, of the pharyngeal membranes. These changes in most 
cases, have extended to and involved all of the nasopharyngeal mem- 
branes. 

Chronic granular pharyngitis, or so-called clergyman's sore throat, 
has a similar pathology to that described above, but with swollen and 
inflamed lymph follicles. This condition seems to be a result of exces- 
sive use of the voice. 

Chronic atrophic pharyngitis has a similar etiology and the diagnos- 
tic signs are also similar to atrophic nasopharyngitis with which it is us- 
ually associated. 

Etiology. — The causative factors are similar or the sa^ne as those 
of nasopharyngitis. Lesions of the cervical and upper thoracic and 
chronic focal infections such as tonsillitis, sinuitis, etc. are the common 
causes. 

Treatment. — The nature of the treatment should be determined 
])y the causes found. The nature of the pathology requires long contin- 
ued treatment and careful attention to all causes. Thorough osteopathic 
corrective work, the removal of all sources of focal infection, proper at- 



276 The Practice of Osteopathy 

tention to any gastro-intestinal perversions which may be causing auto- 
intoxication and thorough cleanhness of the parts by gargling with some 
cleansing, nonirritating solution and by irrigation. 

In most cases there is a considerable collection of adhesions in the 
nasopharynx or posterior nares or in both. Enlarged "posterior tur- 
binate bodies" and the extension of the inferior turbinates into the pharynx 
are also common results of the hypertrophic process. Complete surgical 
removal of this excess tissue and the after treatment as described above 
under chi'onic nasopharyngitis are frequently required to obtain com- 
plete and permanent results. 

These cases can be successfully treated if the proper attention is 
given to aU possible causes in each individual case. It is the individual- 
ization, the specific and detailed attention to the cause or causes, and 
such treatment continued for sufficient time, that will obtain results. 

In atrophic pharyngitis, normal nutrition to the parts and usually 
to the entire system must be restored. Many such cases are secondary 
to systemic anemia or to rheumatic intoxication. A careful examination 
should be made for evidence of systemic causes. In many cases, I be- 
heve that thorough osteopathic corrective work applied to the mid and 
lower spine is the most essential part of the treatment. Other than this 
the local treatment as described under atrophic rliinitis appUes here. 

Tonsillitis 

There is perhaps no other organ of the body, diseases of which have 
caused a greater variance of opinion relative to treatment than the ton- 
sils. There are those who beheve that every hypertrophied, atrophied, 
or infected tonsil together with its fellow of the opposite side should be 
removed. There are also those who believe that no tonsils, regardless 
of their pathology, should ever be removed. These are the radicals and 
their views are not at all in keeping with present day facts. 

Those physicians and surgeons who have tried to arrive at some safe 
conclusion on this subject, beheve that there are certain methods of non- 
surgical treatment which are effective in aany cases and they also beheve 
that in other cases, tonsillectomy is imperative. 

Functions of tlie Tonsils. — Many and varied functions for the 
tonsils have been held by various theorists such as: the absorption of the 
products of salivary digestion; the secretion of an amylolytic ferment; 
tl at they are atavistic structures and therefore have no function; that 
they ehminate systemic toxins ; that they serve as culture tubes for the 
production of vaccines; that they protect the deeper cervical tissues from 



The Practice of Osteopathy 277 

bacterial invasion; the theory of internal secretion and a score of other 
theories which so far, have never been substantiated by either clinical 
or experimental evidence, 

The hematopoietic theory or the theory of blood formation has a 
rather definite basis because such a function would be possible from the 
histologic structure. The formation of small lymphocytes has been at- 
tributed to tonsil tissue (Flemming) and this view has been generally 
accepted. Some of the lymphocytes however, find their way through 
the epithelial walls into the crypts and are discharged as ''mucous 
plugs", while others are carried by the efferent lymphatics into the cir- 
culatory system. In this respect, the tonsils, l^ke other lymphoid tissue, 
produce l^maphocytes which are essential constituents of the blood. 
This function is particularly marked during the growing period, but this 
function is also highly developed in all lymph nodules during this period, 
and in the growing child there is an abundance of such tissue and thus 
it seems that the tonsils, while important to the growing child, would not 
be at all indispensable structures. 

Some physicians claim to have observed deficiencies in growth and 
development of children whose tonsils had been removed during the 
first ten or fifteen years of hfe, but this is not commonly accepted. The 
tonsils have their greatest cellular activity during the growing period and 
unless chronically hypertrophied they atrophy during adult hfe, 

Tonsillectomy 

We may safely conclude from this evidence, that in the growing 
child, it may be well to retain the tonsils providing they are not directly 
affected in such a way as to endanger the general health of the child, 
but that there is Httle, if any, danger in their early removal. In adults, 
there seems to be no reason why they should not be removed in cases in 
which there is evidence of involvement beyond restoration by treatment 
or those cases in which there is evidence of toxic absorption. 

When surgical removal of the tonsils is indicated, the complete re- 
moval or tonsillectomy should always be done. A careful and complete 
enucleation of the tonsils when properly done will never be followed by 
any untoward results other than the temporary surgical sore throat. 
There is never any excuse, much less a reason, for partial removal of the 
tonsils or tonsillotomy, because such operations never accomplish the 
desired result and they nearly always require tonsillectomy later. 

In association with a reputable vocal teacher I have studied the re- 
sults of tonsillectom}^ on the voice. In none of the twenty cases studied 



278 The Practice of Osteopathy 

was there any impairment following the operation, but on the other hand 
sixty per cent were improved either in range of pitch, quality or endur- 
ance, in addition to their being more free from laryngitis, pharyngitis, 
etc. for which the operation was done. Doctors Ruddy, Edwards and 
Reid of our profession have told me of similar experiences, so I am certain 
that tonsillectomy properly done will in selected cases, improve the 
voice. 

Acute Tonsillitis 

Acute tonsiUitis is an acute infectious and often a contagious disease 
characterized pathologically by inflammation of the tonsils. Some 
authors differentiate between follicular tonsillitis in which the crypts or 
lacunae are involved, and parenchjmiatous tonsiUitis in which the paren- 
chyma is involved. 

Etiology. — The predisposing and exciting causes are the same as 
in other acute infections of the upper air passages except that there is 
usually a chronic tonsiUitis as a result of some previous attack. 

Symptoms and Diagnosis. — The symptoms also are similar to 
other acute infections of the nasopharyngeal tract, with sore throat, 
variable temperature, headache, etc. By direct examination of the phar- 
ynx, the protruding masses with white or yeUow patches are readily seen. 

Treatment-- — Infection, drainage and eUmination are three words 
inseparable in the therapeutics. The local treatment (I doubt if many 
will agree) in either acute or chronic tonsilUtis is essentially the same — 
radical aspiration drainage. In all cases, except young children who will 
not permit it, I place a vacuum cup directly over the tonsil and apply 
as much vacuum as can be obtained. This treatment will, when properly 
done, empty the crypts of all pus. This accompUshed, each crypt is 
probed with a cotton appUcator dipped into phenol-glycerine. 

Cervical and upper thoracic treatment and deep relaxation of the 
sub-tonsil tissues to increase the normal blood supply and to decrease 
congestion by drainage eUmination are essential. The lower thoracic 
and lumbar should receive due attention for the purpose of increasing 
general elimination. The diet and other treatment are no different from 
that in other infectious fevers. 

Peritonsillar Abscess 

(Quinsy Sore Throat.) 
Peritonsillar abscess results from the collection of pyogenic bacteria 
and pus formation between the tonsil and the pillars of the fauces. It 
is perhaps a result of the closing of an infected crypt causing deep pene- 
tration of the pus. 



I 



The Practice of Osteopathy 279 

Diagnosis. — The symptoms are those of acute tonsillitis but us- 
ually more marked and with one tonsil decidedly more protruding than 
the other. In some cases the location of the abscess can be seen and it 
is comparatively easy to open with a knife or probe, but in many cases 
the abscess is so situated that it cannot be located except by exploratory 
probing. 

Treatment. — Drainage by direct incision of the abscess pocket is 
indicated as early as a definite diagnosis can be made. There is no defi- 
nite technic to be followed except to observe certain general principles. 
If the ''pointing" of the abscess can be located, it is comparatively easy 
to make a good, free, direct incision and accomplish complete drainage. 
In many cases the only way to locate the pocket is to employ a probe or 
small, long, scalpel and explore between the pillar and tonsil until the pus 
pocket is found. As soon as this is located the pus pours out around the 
probe and this gives the location. Free drainage by means of a Kberal 
incision should then be made. Aspiration of the pus pocket and fihing 
with phenol-glycerine is effective after drainage has been obtained, but 
a hberal drainage must be maintained. 

The non-surgical treatment as described under acute tonsillitis is 
to be applied here. 

Chronic TonslSlltIs 

Chronic tonsillitis usually is the result of one or many attacks of acute 
infections of the tonsils. Occasionally cases of marked chronic tonsillitis 
occur in which the patient denies ever having had an acute attack. 

The pathology consists of hypertrophy of the lymphoid tissue and 
connective tissue. 

Diagnosis. — The purpose in diagnosis is not to determine whether 
the tonsil is hypertrophied but to determine whether the tonsil is causing 
any local or general physiological perversions and if so, whether local 
treatment or surgery should be applied. 

The direct examination should be made very carefully, because 
otherwise a bad tonsil may be readily overlooked. The mere fact that 
a tonsil is large or has open crypts from which a whitish mass may be ex- 
pressed does not mean that such a tonsil is directly responsible for local 
or systemic physiologic perversions. 

The examination should be made by means of a tongue depressor, 
tonsil retractor and a good head mirror and reflecting lamp. Every 
part of the tonsil and surrounding pillars should be carefully examined. 
Firm pressure applied against the tonsil from in front and behind will 



280 The Practice of Osteopathy 

often force material from the crypts or out around the capsular margin. 
Any such material thus expressed should be examined microscopically. 
By probing the crypts with a small pointed cotton-wound probe and 
staining the material obtained, the condition of the deep parts of the 
tonsil can be determined. 

The sj-mptoms in every case, are to be considered with the micro- 
scopic findings, but there are cases in which either of these, together with 
appearance on direct examination, is sufficient to determine the advisa- 
bility of tonsillectomy. 

In general, we may say that the following factors would indicate 
tonsillectomy. 

1 . Chronic, recurrent tonsillitis with or without compHcations, which 
does not respond to non-surgical treatment. 

2. Positive evidence of arthritis of any form with microscopic evi- 
dence of some virulent organism, such as staphylococcus, streptococcus 
or long-chain pneumococcus, present deep in the tonsillar tissue. 

3. Any persistent discharge of pus from the tonsil in which the 
microscope shows the presence of virulent bacteria and which will not 
be relieved by treatment. 

4. Markedly hypertrophied tonsils which directly interfere with the 
voice, deglutition or respiration and which do not respond to treatment. 

5. Persistent focal infections of the middle ears, ur sinuses or root 
abscesses which do not respond to treatment and in which case there is 
a virulent infection of the deep parts of the tonsil, shown by microscopic 
examination. 

The above are only general conditions and there are probably many 
other indications or groups of sjmiptoms that would indicate tonsillec- 
tomy. In most cases, unless the findings show positiveh^ that tonsillec- 
tomy should not be delayed, we advise treatment. If treatment does 
not restore to normal, it will probably reduce the time of the surgical 
sore throat following the operation. 

Non-surgical treatment. — The local direct treatment, as we 
practice it, consists of: 1. Direct aspiration by means of the tonsil 
cup, applying from fifteen to twenty inches of vacuum. 2. AppHca- 
tion of phenol-glycerine by means of cotton apphcator to the full depth 
of each crypt. H. Irrigation of the crypts by means of a catheter and 
hot salt mixture solution. 4. Syringing of the crypts by means of the 
cathet(?r and phenol 10%, alcohol 20% and glycerine 70%. 

The digital treatment of the tonsil consists of: 1 . Applying pressure 
against the anterior pillar thus forcing the contents out of the tonsil, 



The Practice of Osteopathy 281 

the Ruddy method. 2, By the bidigital technic, the front finger of one 
hand inside, posterior and inferior to the tonsil and the fingers of the 
other hand outside exerting deep pressure and opposing the finger in- 
side. In this way the tonsil can be lifted forward and upward and its 
contents expressed. The digital treatment is not as effective as that 
described above. 

The osteopathic corrective treatment consists of adjustment of the 
atlas and axis and the mandibular articulation and the obtaining of free 
movement of the hyoid and the relaxation of the submaxillary muscu- 
lature and other deep structures. 

This treatment, if followed persistently, will relieve the local symp- 
toms of a very high percentage of cases of chronic tonsillitis, and in many 
cases even the systemic compHcations will be relieved. Whether in cases 
of systemic absorption this is the preferable treatment I am not sure, 
because, once the local condition is improved the patient will usually 
refuse operation and even if the physician finds definite evidence of toxic 
absorption he cannot convince the patient that his tonsils require sur- 
:gery. 



J 



282 The Practice of Osteopathy 



MENTAL DISEASES 

BY 

L. Van H. Gerdine and A. G. Hildreth. 
INTRODUCTION 

The subjects herewith presented, while including certain of the 
most important sections of mental disease, make no claim to complete- 
ness either in the subject matter presented or in the attempt to cover 
the entire field of the psychoses. They cover those portions, however, 
with which we have come in closest touch at the Still-Hildreth Sanator- 
ium, and in which we have the most complete records. I have been 
aided in the compilation of the essential facts and statistics by the able 
staff of the institution and wish to acknowledge especially the valuable 
cooperation of Dr. C. M. VanDuzer in the Dementia Praecox group, 
Dr. H. P. Hoyle in the Manic Depressive group. Dr. B. L. Jemmette in 
the group entitled Delirium, Confusion and Stupor, Dr. J. C. Snyder 
in the Senile Dementia group and Dr. G. S. Elkins in the Involutional 
group. The opinions concerning each type held by Dr. A. G. Hildreth 
are appended under its appropriate heading. I wish to state emphatical- 
ly that the sole treatment carried out in the Macon Institution is specific 
corrective work upon spinal lesions, and it is upon this treatment that the 
statistics are based which are to be found throughout the text. These 
records cover more than 700 cases, including complete histories of the 
patients with the physical and mental findings on examination; these 
represent, therefore, by far the largest body of statistics ever accumulated 
in the study of osteopathic results in mental disorders. While the re- 
sults naturally vary in different types of mental disease the grand to- 
tal shows that more than one-half of all patients admitted recovered. 
Details for each group will be mentioned under its appropriate head- 
ing. WHiile adjuncts such as diet and hydrotherapy have been utilized; 
we certainly cannot attribute any curative value to their influence. 

It should be further emphasized that in no case whatsoever has 
medicine been used as a curative agent. And the same may be said 
of surgery. It has indeed been conclusively proved even in the medical 
world that medicines and surgical procedures are absolutely ineffective ; 
from the osteopathic viewpoint this of course is perfectly reasonable 
since the theory calls for definite lesions as causative factors and these 
lesions can hardly be reached other than by the osteopathic method of 



The Pkactice of Osteopathy 283 

correction. The results obtained, therefore, could only be attributed 
to the genuine osteopathic principle enunciated by Dr. A. T. Still who 
kept in close touch with the work and gave it his approval up to the 
time of his death. He had always maintained that the osteopathic prin- 
ciple could accomplish remarkable results in this field and considering 
the previous inefficiency of any other method his confidence has been 
fully justified. 

Dementia Praecox 

This condition refers to mental disorders arising usually during 
the period of puberty or adolescence, therefore, between the ages of 
fourteen and twenty-five for the most part, although apparently similar 
cases may arise in later years. The term dementia refers to mental de- 
terioration and enfeeblement, while "praecox" signifies adolescence, 
though some writers infer that the term praecox may be used to indi- 
cate the early or precocious development of the mental enfeeblement. 
Certain it is that in most cases deterioration, with its resulting symp- 
toms of mental enfeeblement giving rise to the term dementia, usually 
occurs in time, though by no means always early. It is a chronic pro- 
gressive disease which may terminate in a complete loss of mentahty; 
in other cases it may become arrested in any stage and remain so perma- 
nently; in still others it may recover, though this is rare. By reason 
of the variability of the symptoms, three groups are generally recog- 
nized, first suggested by Kraepehn. Each is differentiated by more or 
less characteristic symptoms and referred to under the head of the Hebe- 
phrenic, Catatonic and Paranoid types, although all have certain symp- 
toms in common and there are mixed types. 

Etiology. — According to the authorities some form of hereditary 
factor can be found in some fifty per cent or more of all cases; this is 
supposed to create a predisposition, a natural weakness of the nervous 
system, which renders it unable to bear the ordinary storm and stress 
of fife, so that the, mechanism becomes according to the French expres- 
sion, "wrecked upon the rock of puberty or adolescence;" in other words, 
a premature giving way of the nervous system, being inherently un- 
able to stand the strain of life. Another suggestion is that it represents 
the outcome of abnormal types or reactions of the individual to the 
environment, with a failure of proper adjustment to surroundings and 
the formation consequently of mental problems which to the patient are 
incapable of solution. This may be called the psychological theory. 
The most commonly accepted idea, however, is the physical causation. 



284 The Practice of Osteopathy 

According to this the disease results from autointoxication, the intoxi- 
cant arising from the disturbances of the glands with internal secretions, 
more particularly the sexual glands. This endocrine theory is supposed 
to be supported by the fact of the appearance of this disease most com- 
monlj^ at the time of puberty and shortly thereafter. 

The osteopathic conception fits in very well with this latter view, 
inasmuch as the spinal lesions are quite capable of explaining not only 
a disturbance of innervation to the glands with the resultant interfer- 
ence in their normal secretion, but also could produce disorder of the 
circulation and nutrition to the brain. 

Symptomatology. — Although each variety of Dementia Praecox 
has special symptoms characteristic of the type there are certain symp- 
toms common to all forms, and these will be first considered. All the 
functions of the mind in the course of time tend to become disturbed 
and to be weakened, but in the earUer stages we find marked differences 
as regards the disturbance of different functions, thus memory and ori- 
entation in most cases seem good; on the contrary, attention and associ- 
ation of ideas somewhat poor. Emotional life is almost alwaj^s marked- 
ly affected, even in the beginning. Very commonly at first there is de- 
pression to be followed later by expansive feelings and then by apathy 
in general. The will power is altered early and the conduct is apt to be 
peculiar. The judgment becomes impaired. All of these symptoms 
mentioned are deviations from the normal in the patient and therefore 
presuppose that the patient was formerly normal. This should sharply 
differentiate the praecox group from cases of defective development 
(imbecility or idiocy). In this latter group there is an arrest of devel- 
opment of the mind, whereas in praecox there is a loss in a developed 
intellect. We see a young patient, for example, who has lost interest 
in things about him, neglects his work at school or at home, remains alone 
for long periods of time and seems unwilling to mingle with other peo- 
ple. He gives the impression of one depressed and worried about some- 
thing he is trying to solve, perhaps he mutters to himself or gives way to 
unprovoked laughter, he may refuse to eat, or to talk unless questioned 
and may even then not answer. When he does talk it will be discovered 
that he knows perfectly well where he is, and knows people around him 
and understands everything that is going on; his memory will be found 
good, he can usually recall past incidents and tell what he has been do- 
ing recently. As the condition progresses, however, while the patient 
may still for a long time retain fair orientation and memory for past 
events, his accumulation of recent ideas will be found poor, so that he 



The Peactice of Osteopathy 285 

will recall them with difficulty. We notice that it is difficult to get the 
patient's attention and concentration seems to be impossible, he may 
answer a direct question, but immediately seems to be occupied with other 
thoughts and it takes some little effort to gain his attention again. If 
he continues to talk it is plain that the association of ideas is poor, giving 
rise to disconnected phrases which usually come forth sluggishlj^ and 
without show of emotion. Dissociation of ideas occurs; that is, different 
ideas expressed may practically contradict themselves. For example, 
the patient may say he is a king and yet when asked to sweep the floor 
will do it perhaps without hesitation, not considering that is hardly the 
kind of work a king would do. The dissociation is also marked in the 
contradiction found between the content of the thought and its associated 
emotional idea, for example, the patient may speak of a near relative as 
dying recently, yet with no show of emotion, even with a meaningless 
laugh. This dissociation may ultimately result in complete incoherence, 
in which no sense can be found whatsoever in his speech. Emotional 
indifference is noticeable early and sluggishness of reactions to stimuli, 
even failure of such reactions ; the patient will neglect himself, stay away 
from meals, express no desires and make no complaints. In the earlier 
stages, however, the patient who may have been for some little time 
apathetic, suddenly without apparent cause becomes angry, noisy, and 
possibly violent and destructive, again gradually relapsing into his quiet, 
apathetic state. The thought content is commonly associated with 
delusions, that is obviously false ideas, but which the patient is unable to 
perceive are false. Delusions of persecution are most common, the pa- 
tient feeling in a dim way that everything is not right ; and in attempting 
to explain to himself the reason, often attributes causes to people or forces 
outside of himself, and on account of the feehng of bodily discomfort, 
also by reason of the depression, he explains the external forces as un- 
friendly to himself. Hallucinations may be present and furnish the 
material around which the delusions form; on the other hand halluci- 
nations may result from the delusions. By hallucination is meant a false 
sense perception, as the patient may state he sees someone before him 
who is not there, or that he hears voices from individuals who are not 
around him ; he may also complain of receiving electrical shocks, or wire- 
less messages, which he usually states come from his persecutors. Symp- 
toms of this nature form a good example of the so-called split personality, 
or "schizophrenia," wherein certain idea complexes are split off from 
the main personality and address themselves to the main portion, the 
patient attributing these noises (voices), sensations (visceral and tactile), 



286 The Practice of Osteopathy 

tastes and smells to an objective rather than a subjective source and 
subsequently forming delusions. However, unless we are dealing with 
the paranoid form the delusions are fragmentary, transient and absurd. 

Hebephrenia. — This is a progressing mental enfeeblement, ter- 
minating usually in deterioration, and without showing marked pecul- 
iarities in thought or action aside from the progressing deficiency. The 
patient appears in general inactive, lacking in energy and ambition, 
indifferent, depressed, incapable of much concentration and hence the 
efficiency becomes progressively impaired until he is unable to accom- 
phsh anything. From time to time there may be periods of confusion, 
depression, passivity, at other times periods of excitement. 

Catatonia. — In this form the general symptoms are similar to 
those of the simple type above described with the addition of the special 
symptoms referred to as catatonic excitement and catatonic stupor. 
The excitement period is manifested by an unrest and monotonous ac- 
tivity, stereotyped actions and speech, the patient constantly repeating 
some act, such as moving the hand, foot or head over and over again 
in the same way, or repeating the same word or phrase indefinitely. 
This occurs apparently involuntarily, the actions being automatic in 
character. The patient who has been in a semistuporous state may 
pick up a glass or chair and without show of emotion break it against the 
wall. In catatonic stupor the patient may show in the lighter degrees 
a simple loss of interest and feeling with sluggish reaction to stimuh, 
or a profound inactivity and stupor in which state he cannot apparently 
be reached by any stimuli; nevertheless, he apparently retains conscious- 
ness. In this type we observe the interesting symptom of negativism 
in which the patient always does the opposite of what he is requested, 
or refuses outright to obey any command. There may be a refusal of 
food so that the patient has to be fed by a tube, mutism may be present, 
the patient may go for weeks or months without saying a word; stereo- 
type of attitude results in cataleptic poses and rigidity, in which the 
patient may maintain any particular pose for a prolonged period of 
time, and if placed in some other attitude may similarly retain the new 
attitude for a long time. This constitutes the so-called wax like rigidity, 
the patient reminding one of a wax figure. Pathologic suggestibility 
occurs in which the patient imitates movements, or repeats words and 
phrases that are spoken or performed before him. 

Paranoiac Form. — In this type delusions predominate and are 
characterized by variability, inconsistency, illogicahty and transitori- 
ness on the one hand, with many gradations to the opposite extreme 



The Practice of Osteopathy 287 

where they become more or less fixed, and often dovetail into each other 
forming apparently a systematic whole. They tend to be usually of a 
persecutory and hypochondriacal character and in later stages when the 
mind is distinctly weakened are often of a grandiose type. Sometimes 
the patients have some kind of explanations for them and at other times 
none whatsoever, and they are often curiously dissociated from the 
emotional accompaniment. The patient may state there is poison in 
his food, in an indifferent tone of voice or even with a laugh; he may 
claim that his teeth are all set in wrong and offer no explanations to 
these obviously false ideas. The patient commonly thinks that some- 
body "has it in for him," someone will do him mischief, will kill him, 
that people are talking about him and criticizing him, everything that 
he hears or reads he thinks has some bearing on himself, so-called "de- 
lusions of reference. " Hallucinations may be present, the patient hear- 
ing voices, or receiving impressions or ideas which he claims come from 
without. These external impressions he misinterprets as voices or 
forces which are accusing, threatening and slandering him. Later on, 
the patient tends to change from the depressed persecutory stage to an 
expansive one, when he claims he is some celebrated person, king or 
president, or pope. The impairment of the judgment is clearly dem- 
onstrated in these cases since the patient who may claim to be the king 
of England may beg the attendant to change his place at the table or 
for a postage stamp. 

Pathologic Anatomy. — This is obscure. Since a certain pro- 
portion of cases recover, there can evidently be no degenerative changes 
at the outset, though some cases deteriorate fairly early, others only 
after several years. In some chronic cases there have been observed de- 
generative changes in the cortical cells. 

Diagnosis. — First, the common age of onset during puberty and 
adolescence, fourteen to twenty-four in the vast majority of cases, this 
being the only common mental disease occurring during this age period. 
Second, the progressive character terminating in mental enfeeblement 
or deterioration, that is "dementia" proper. Third, the evidence of 
defect or deficiency symptoms indicating that the patient's mind has 
allered in the sense of deterioration from its former normal condition, 
whereas, in imbeciles or idiots the mind has failed to develop in the first 
place. Fourth, in the earher stages particularly the marked dissociation 
of the brain powers, some being well maintained as memory and orienta- 
tion (that is knowledge of time and space), others being weakened, such 
as judgment, power of attention and the like. Fifth, the early appearance 



288 The Practice of Osteopathy 

of the emotional defect, a remarkable indifference and apathy of the 
patient to people and surroundings, the patient being unsocial and tak- 
ing no interest in anything. Sixth, all the peculiar motor reactions, 
which are mentioned above under the catatonic head, and which very 
rarel}" occur in any other mental disorder. Seventh, the delusional 
content nearly always refers to the patinet's exterior, forces outside 
of him, people or things which are exerting an unfavorable influence 
upon him, delusions of persecution and reference. The patient practi- 
cally never accuses himself, as is the rule in cases of true melancholia, 
never blames himself, but always the other party or the other force out- 
side of him. Eighth, the delusions of grandeur are usually indicative 
of a stage of deterioration. 

Prognosis. — Some authorities are inclined to doubt if any case 
ever completely recovers, claiming that in apparent recovery it may 
have been a question of mistaken diagnosis, or that the recovery is more 
apparent than real, that the patient is not truly ell, or ill have a re- 
lapse, so that a permanent cure will be impossible. Other authorities 
admit the possibiUt}^ of recovery though in a very small minority of 
cases. The statistics of the Still-Hildreth Sanatorium, covering more 
than two-hundred fifty cases show total recoveries of at least one- third. 
This includes all types and all stages of progress, many being advanced 
on entrance. Of the less advanced cases and those of not more than 
two or three years' standing there have been some fifty per cent recov- 
ery. Many cases make improvement or become stationary in greatly 
improved condition, but are not included in the thirty per cent. Of 
the three types, the catatonic offers the best prognosis, the hebeprhenic 
the poorest, while the paranoiac occupies an intermediate position. 

Treatment. — Of the etiologic factors above mentioned, that of 
autointoxication, resulting possibly from endocrine disturbances or 
other sources, is most generally accepted in the medical world and agrees 
excellently with the osteopathic point of view. Spinal lesions are regu- 
larly found more particularly in the dorsal region, which are quite capa- 
ble of disturbing the innervation to the glands; therefore, their nutrition 
and activity. A correction of these before the disturbance has continued 
too long, and hence before detrioroation has set in, should theoretically 
normahze the glandular condition and therefore prevent deterioration 
and enable the patient to recover. Such is the probable explanation of 
the results, and in many cases the recoveries were obtained in patients 
previously considered hopeless. 



The Practice of Osteopathy 289 

Remarks by Dr. Hildreth 

In a great majority of the cases the cause Hes in the interference 
between tKe fourth dorsal vertebra and the eighth, which analyzed means 
a disturbance of the great splanchnic nerves, through whose interference 
would be caused the toxic condition and even the sexual disturbance 
described in so many cases from standard authorities. The same lesion, 
if deep seated enough, could produce an interference with the vasomotors 
and reflexly interfere with the circulation to the brain. In many we also 
find a first, second or third cervical lesion. The effects of these lesions 
on the equiUbrium of the circulation to the brain are easily traced through 
the superior cervical sympathetic ganglia. These lesions, namely, the 
mid-dorsal and upper cervical, especially when corrected in the earlier 
stages, have thus far proven to produce successful results. In a lesser 
number of cases we find the cause to be from the first to the fourth dor- 
sal vertebrae; our reasoning here being that the interference or the phy- 
sical disturbance must be so deep that it reaches and interferes with the 
deeper nerve currents, both downward and upward, thus disturbing the 
equilibrium of the circulation to the brain. We have found this class 
to be the hardest to respond to treatment ; however, that may be due to 
the fact that the physical defects at that point are harder to correct. 
Osteopathic treatment applied to the lesions above described without 
question offers therapeutics of intrinsic value to this class of patients. 

Delirium, Confusion and Stupor 

This clinical group has become well estabhshed, not only in its recog- 
nition from the dominant symptoms as indicated above, but also from 
rather definite causes. The immediate cause seems to be an abnormal 
blood state, or so-called toxemia, which may result from infectious dis- 
eases, or states of exhaustion, or autointoxications, or foreign poisons; 
the poison acts as an irritant to the brain. In states of exhaustion so- 
called "fatigue bodies" are formed and are apparently toxic in character. 
The autointoxicants may have various sources, such as chronic kidney 
disease, or diabetes, and the like. The most important of the foreign 
poisons are alcohol and morphine. This morl^id group is further charac- 
terized not only ])y a toxic cause and dominant symptom complex of de- 
lirium, or confusion, or stupor, but by a similar onset and course. The 
onset is usually acute and the course somewhat wave like, gradually reach- 
ing a climax and subsiding, or resulting in death or becoming chronic. 
To emphasize the clinical symptoms of confusion which is so important 



290 The Practice of Osteopathy 

the term "acute confusional insantiy" has often been used, or "amentia/' 
according to the common German terminology. Hallucinations also 
play a prominent part, particularly those of vision; hence, another com- 
mon appellation, "acute hallucinatory confusion." Heredity is men- 
tioned at most as creating a predisposition, though often the personal 
and family histories show no such evidence whatsoever. Intellectually 
there is a definite lack of orientation, the patient is unable to identify 
himself or his surroundings in time and space. He cannot clearly under- 
stand what goes on around him, that is, consciousness is " clouded ;"^ 
the clouding may be of such extreme degree the patient's mind becomes 
blank, due to complete psychic inhibition. This is referred to as stupor. 
The emotional life plays a secondary role subordinate to the intellectual 
content. The patient may be greatly excited for example, resulting from 
a frightful hallucination. The hallucinations are mainly of the visual 
type and are almost always present. The patient hves in a perpetual 
state of sense deception as if he were constantly dreaming; the hallu- 
cinations for the most part are of distressing, disagreeable or even fright- 
ful character. These may give rise to delusions, which are manifold, 
often fantastic and usually transitory. 

Physical changes are always found associated with the disturbed 
mental status. If it arises during the active stage of an infectious process 
there is of course the high temperature and all other physical signs of fever. 
In a certain number of cases with temperature no definite signs can be 
found indicative of any of the well known fevers, hence has been called 
by various names, such as "Bell's Delirium," "Acute Mania Gravis," 
or "Acute Febrile Delirium. " This ordinarily runs an acute rapid course 
with very high temperature, very marked delirium, followed by stupor 
and usually death from exhaustion. Even though no temperature be 
present the physical condition reminds one very much of that found 
in fever diseases. There is the lost appetite, resulting emaciation and 
malnutrition, insomnia, exhaustion, etc. 

Osteopathic Theory.— While it may be admitted that the var- 
ious factors mentioned above may take part as exciting or predisposing 
causes, it is obvious that in numerous instances mental disorders do 
not arise whatsoever, even when the patient is subjected to these factors. 
There must necessarily be other elements essential to produce the psycho- 
sis. The osteopathic theory comes in at this point to fill in and com- 
plete the chain of causes and to initiate the onset by the introduction 
of the idea of nutritional and circulatory disturbances resulting from 
the spinal lesions. 



The Practice of Osteopathy 291 

The records of the Still-Hildreth Institution show 18 of the toxic 
type, in which the poison is derived from without, who were treated, 
with 17 recoveries. There were 25 cases connected with the infection 
and exhaustion group, with 20 revoveries. 

Remarks by Dr. Hildreth 

In this group we have to do with blood disorders, resulting from 
the infections, conditions producing exhaustion, and the various tox- 
ins, or poisons, whether originating within the body or derived from with- 
out. These disorders are largely functional in character, resulting from 
brain irritation due to the toxemia or disturbance to the centers of nu- 
trition. The main object of the osteopathic treatment, therefore, is 
to aid ehmination and regulate and build up the nutrition. In most 
of the patients the physical lesions are found in the mid dorsal area, 
chiefly from the 4th to the 7th, and in the cervical region, the 1st to the 
3d. In aiding the kidneys in ehmination the 10th and 11th dorsal ver- 
tebrae must be looked after. These conditions commonly respond very 
rapidly to the treatment and represent one of our most successful groups 
so far as results are concerned. 

Manic Depressive Psyclioses 

The psychoses which are brought together under this classification 
include mental disorders which at first glance would appear to be of very 
wide variation, namely, conditions of maniacal excitement and those 
of depression. Further consideration, however, reveals the very evident 
reasons why they should be united as sub groups under the one head. 
The fact that these two mental states of seemingly opposite character- 
istics often appear alternately in the same individual, that in certain cas- 
es of each type there is a wave like feature in the nature of the attack 
and the frequency with which they tend to recur, together with other 
points of similarity in respect to duration, prognosis, etc., tend to point 
to their very close relationship. Kraepelin was the first to draw at- 
tention to these facts and advocate the present convenient and widely 
accepted classification of these disorders. 

The outstanding feature is the disturbed emotional state which 
dominates and overshadows all other symptoms and is fundamentally 
the same whether expressed through the excitement of mania or the de- 
pression of melancholia. 

Etiology. — Heredity is considered an important factor. Various 
authorities claim to have demonstrated direct hereditary influences in 



292 The Practice of Osteopathy 

as many as eighty per cent and more of cases. Individual predisposi- 
tion resolves itseK into a matter of constitution and temperament in which 
there seems to be a greater tendency among those who are subject to the 
emotional extremes. 

Early adult hfe is by far its most frequent period of onset, though 
it may arise also somewhat later. In certain cases the beginning of the 
disorder dates from some psychic or emotional shock. Just what impor- 
tance these factors have as causes is little known since other cases devel- 
op in which the constitutional element alone seems responsible and no 
immediate exciting cause can be demonstrated. 

The osteopathic view:^oint emphasizes the all important influence 
of spinal lesions as exciting factors. In individuals who have a tenden- 
cy to this reaction their presence disturbing the cerebral circulation 
and nutrition may act as the direct causative factor. 

Manic Phase. — The manifestation of this condition is brought 
about by the release of the inhibiting influences which normally govern 
all psychic function. Various terms as hypomania, acute mania, deUr- 
ious mania, etc., have been used to differentiate the different degrees 
in which the symptoms appear. 

In the milder types we find the following symptoms present. There 
is a marked feeling of well being. The patient, having lost sight of his 
personal limitations, feels a consequent exalted opinion of himself. His 
conduct is often rather boisterous, he talks a great deal, often swearing 
and using obscene language. He is inconsiderate of others and tries 
to impose his will upon those about him. There goes with this a certain 
unstabihty of the emotional tone as manifested by the quickly changing 
feeling of good humor, irritability and anger. There is a rapid flow of 
ideas with a marked loss in the ability to concentrate and direct thought. 
The ideas which pass through the mind do not coordinate themselves 
toward a definite goal, but deviate from the course of consecutive think- 
ing by any passing association. Again there is a restlessness and activity 
beyond all normal bounds. The individual feels strong physically and 
mentally. The appetite is unusually good and if activity is not too 
extreme there may be a gain in weight. The period of sleep is dimin- 
ished and the feeling of fatigue is reduced. 

In the more exaggerated cases the flight of ideas becomes more 
marked, the associations are more rapid and supei-ficial and the atten- 
tion is focused but momentarily. Illusions and delusions may be present 
due to the imperfect preceptions from inability to concentrate attention 
and from abnormal associations. Rhyming speech, disconnection of 



The Practice of Osteopathy 293 

phrases and even apparent incoherence are often present. The state 
of mind may be such that the patient tears his clothing, breaks up furni- 
ture, jumps, dances and shouts and often will not take time to eat. The 
most extreme cases which refuse food over some period of time progress 
rapidly to exhaustion and measures to conserve strength become im- 
perative. 

Depressive Phase. — In this phase of the disorder are encountered 
manifestations which are in direct contrast to those presented in the 
manic phase. In place of the exalted emotional state there is a depression. 
There is a tendency to worry over trivial matters of the daily routine 
and of instances in past life. Introspection is the predominant mental 
attitude and the whole outer world is colored by the inner feehng of 
worry and uncertainty. Replacing the rapidity of thought in the manic 
phase there is a distinct slowing of mental processes in the depressive 
phase. Thinking is more dihcult and labored, questions are answered 
slowly and with an apparent effort and there is usually a tendency to 
avoid social life. 

Again replacing the excessive activity in mania the depressions show 
a retarded action. There is disinclination or disabihty toward any 
effort either motor or mental. The patient feels weak and incapable of 
effort, the body assumes a bent attitude and the facial expression is one 
of despondency. The appetite is usually impaired with resultant loss 
of weight, the bowels are sluggish, the period of sleep reduced. 

In the more exaggerated cases the retardation may be complete. 
Introspection is carried to the degree where the patient tries to take 
unto himself the responsibihty for all the sin in the world. He himself 
is the arch sinner and he feels himself the subject of punishment by di- 
vine wrath in a manner in which no other individual was ever punished. 
Also the introspection tends to produce various hypochondriacal ideas. 
The patient may feel that he has contracted some incurable disease and 
that certain bodily functions have ceased operating. 

Mental processes become not only retarded and difficult, but actual- 
ly painful, a symptom which has been termed psychalgia. Suicidal 
tendencies are also quite frequently present. 

In extreme conditions the patient may become so retarded in thought 
and activity that he apparently receives no stimulus from the outer 
world. He lives in a more or less stuporous state, even requiring that food 
be administered by tube. 

Circular Insanity and Mixed Forms- — In addition to the condi- 
tions in which siiiipl}' mania or inclaiicholia are manifest there are cer- 



294 The Practice of Osteopathy 

tain cases which show variations and combinations of these forms. 
A common type is that in which there is an alternation of the manic and 
depressed conditions. The patient may pass directly from one state 
into the other, or there may be an intervening period of lucidity. The 
term circular insanity has been applied to this type. Other variations 
are those in which there are recurrences of the manic or depressive at- 
tacks often at more or less regualr intervals, each recurrence being a prac- 
tical repetition of the preceding. 

There is also possible a considerable interminghng of the character- 
istics of the two types. In the manias may occur difficulty of thinking, 
passing feelings of depression and even almost stuporous conditions. 
In depressions there can exist a marked degree of restlessness and activity 
and a rapidity in the flow of ideas. 

Prognosis. — The outlook for recovery from the individual attack 
is good. The attack may last from a period of days to one of a number 
of months and recovery comes with rarely any evidence of mental deteri- 
oration. There is a tendencj^ to recurrence of the trouble. In fact 
recurrence is the rule rather than the exception. In the osteopathic 
handling of these cases it has been the endeavor to demonstrate that 
the correction of lesions had a tendency to lessen the duration of the in- 
dividual attack and reduce the tendency to recurrence. Judging from the 
experience thus far gained in the observation of cases under treatment 
during the attack and the comparative few recurrences reported both 
of these aims have been attained. 

Treatment. — The osteopathic measures are aimed at the cor- 
rection of the spinal lesions, especially those located in the upper dor- 
sal and the cervical regions. Some reflex effects from lesions in more re- 
mote areas may have their influence so that it is wise to look to the cor- 
rection of any other structural variations when present. 

Remarks by Dr. Hildreth 

The mental disorders of this type are purely functional and maj^ 
cover a broad scope as to causes; however, from the osteopathic view- 
point a great majority of them seem to have as their specific exciting 
cause, lesions in the upper dorsal and upper cervical regions. The treat- 
ment should be appHed specifically to the cause which may range any- 
where from the 1st to the 8th dorsal, or from the 1st to the 3d cervical, 
covering the nutritional and circulatory centers and thus controlling the 
nutrition and circulation to the brain. There can be no question but 
what the osteopathic theory of adjustment of physical defects forms the 



The Practice of Osteopathy 295 

basis of permanent cure, since many of our recoveries had been previously 
under other methods of treatment without results. Our records cover 
over 200 cases with recovery in more than two-thirds, and very few 
recurrences up to the present. 

Involutional Psychosis 

In the mid years of life, between forty and sixty, a decline begins, 
which in the older years results in decay; it is especially true at this per- 
iod of the sexual hfe and the organs underlying it. While these organs 
undergo a very definite change constituting the so-called climacteric 
period in women, it is not at first sight so evident in men; however, the 
evidence is that a somewhat similar process, though much slower, tends 
to occur in the male. Associated with the decay of the sexual organs 
is a disturbance presumably of the internal secretions; if this latter dis- 
turbance takes place slowly and evenly the body may not notice any 
marked changes; on the other hand, if it takes place more quickly, or 
unevenly, it may give rise to distinct symptoms which indicate a distur- 
bance of the nervous system in general and often even of the mentahty. 
Hence, the significance of the term. Involutional Psychosis. In a large 
majority of cases the mental disorder is marked by the dominance of de- 
pression and is frequently referred to as melanchoha. For a long time 
it was considered that this represented a special mental disorder having 
little or nothing in common with other psychoses. In recent times Dumas 
has studied this group very carefully and shown that it in reality has very 
much in common with the depressed phases of the Manic Depressive 
Group of psychoses. Kraepelin himself, who was the first to demonstrate 
the unity of the Manic Depressive Group, has accepted the conclusions 
of Dumas and incorporated the Involutional Depressions as a sub type 
of his Manic Depressive Psychosis. Among etiologic factors have been 
mentioned hereditary elements, which have been claimed to have been 
found in at least fifty per cent of all cases, forming presumably a predis- 
position ; it is also stated that a predisposition may be acquired through 
various debilitating causes. Exciting factors are claimed to be present, 
such as mental shock, grief, worry and the Uke. The disease would then 
seem to occur when wc have a combination of exciting factors and pre- 
disposition. Careful consideration will show, however, that no such 
mental disturbance occurs at this age in many people who show evidences 
of such predisposition and of exciting factors, therefore it would seem 
that still other causes were necessary; if we consider the suggestion above 
mentioned that there are atrophic processes taking place in the sexual 



296 The Practice of Osteopathy 

glands leading to a loss of the internal secretions and if we further consid- 
er that this may take place unevenly and in an unbalanced way, thus aid- 
ing in giving rise to the symptoms, we will find a definite point of contact 
for the osteopathic conception. Osteopathically considered, we may say 
that the spinal lesions lead to a disturbance of innervation and nutrition 
to the ductless glands, and therefore produce disordered secretions in 
those patients developing the disease, whereas such a condition may not 
be present in others who^at the same age period do not develop the psy- 
chosis. 

Symptomatology 

The emotional tone of depression dominates the picture. Asso- 
ciated symptoms are anxiety, fears, particulary of impending danger, 
the loss of interest in the external world, with a concentration of atten- 
tion upon self; psychic distress is usually present, often to an extreme 
degree, leading apparently to real mental pain, so-called psychalgia. 
Delusions are usually present and manifold in variety; they mainly re- 
fer to the patient liimself and are of a self -accusatory nature; they fre- 
quently refer to notions of sins having been committed, also unworthiness 
of the patient, of poverty, nihihstic ideas, either about his own body 
or external things. He may claim for example that he has no stomach 
or kidney, or heart, that the external world is unreal and the hke. His 
motor reactions become retarded, or even in the more extreme cases 
inhibited, producing a form of stupor. The inefficiency which results 
along with the psychic pain and distress may determine suicidal tenden- 
cies which are very frequent. Orientation is usually good, the patient 
remaining aware of his own identity and that of his surroundings; the 
judgment of course is impaired so that the patient is unable to appreciate 
the unreality of his delusions ; as a result he sees no hope in the future and 
on account of present sufferings prefers death to life. The patient may 
remain in a perfectly passive mood, giving the appearance of extreme 
depression, paying no attention to the surroundings, possibly mute, 
giving no regard to the necessity of the toilet, paying no attention to 
his clothing and the like. This may continue for hours or days. Food 
often has to be forced on him, possibly even by the tube; the result is 
usually more or less emaciation and may result in marked malnutrition; 
similarly the sleep may be seriously interfered with, even though the 
patient is quiet. The resulting loss of sleep and malnutrition sometimes 
lead to the death of the patient. On the other hand, the patient may 
moan and wring his hands in anguish, walking up and down, crying 



The Practice of Osteopathy 297 

out that he is a sinner and that he wants to die and the hke. This is the 
so-called melancholia agitata. 

The physical symptoms of importance are sleep disturbances, poor 
appetite, with emaciation, cyanosis, often a subnormal temperature, 
low blood pressure, slowed heart action and weakened circulation. The 
hair may become gray, the skin dry and harsh and indeed any of the 
signs of senile decay may appear. 

Diagnosis and Prognosis. — These depend partly upon the men- 
tal symptoms, partly upon the physical. On the mental side is to be em- 
phasized marked depression, with the relatively clear orientation, re- 
sembling the depressed phase of Manic epressive insanity; also the 
dominance of the self-accusatory delusions. On the physical side the 
age period, and the evidence of previous attacks, even though very 
slight. The prognosis from the study of the mental symptoms depends 
on the prefience or absence of signs of defect, or deterioration, as for 
example foolish and silly delusions. On the physical side the presence 
or absence of conditions like Iddney or arterial disease; in general, it may 
be said if the physical findings are negative and the mental symptoms 
show no deterioration there should be a good outlook, particularly if the 
condition has not become too chronic. 

A favorable outlook is always possible if the disease is treated early 
and the lesions disturbing the activities of the glands and of nutrition 
and the circulation are corrected and if the other physical findings are 
negative and signs of deterioration absent. 

Since this is probably only a sub-group of the Manic Depressive 
Psychoses, as has been mentioned above, the results obtained under 
osteopathic treatment are noted under the Manic Depressive group. 

Remarks by Dr. Hildreth 

Our experience with this class of cases invariably lead us to the 
nerve centers which regulate and control the process of nutrition and 
circulation; it is a matter of keeping up normal equilibrium of all organ- 
ic life and especially the circulation to the brain. The basis of the treat- 
ment therefore is to be found in the nutritive centers, as well as those 
centers which control the circulation to the brain, the ductless glands, etc. 

Senile Dementia 

Senile Dementia may be defined as an al^normal weakening of the 
mind arising in old age. As the word dementia implies, the intellectual 
change is quantitative rather than qualitative, the prime characteristic 
of the disease being mental loss rather than mental perversion. 



298 The Practice of Osteopathy 

It is commonly stated that a most important cause of the disease 
is the general malnutrition incident to age. Since only a small propor- 
tion of the aged develop dementia, this is probably only a cooperating 
factor. Other causes mentioned are overwork, emotional strain, trauma- 
tisms, intoxications (especiall.y alcohohsm), cerebral arteriosclerosis and 
perhaps heredity. 

Pathologic Anatomy. — The disease is organic, the brain exhibit- 
ing definite pathological tissue changes. There is an atrophy of many 
nerve cells and a proliferation of neuroglia fibers, so that the cerebrum 
becomes shrunken and hard, with thickened meninges and thinned cor- 
tex, and shows a loss of weight. The cerebral arteries may or may not 
exhibit sclerosis, thrombosis, or miliary aneurisms, with resultant areas 
of softening. The cells show pigmentary degeneration and many of 
the association fibers have disappeared. 

Onset. — The onset of this dementia is usually very gradual, the 
condition not being recognized until rather marked. It occurs mainly 
in the seventies and later and in the late sixties, being rare before sixty. 
It often follows financial reverses, emotional shock, or various diseases. 
The earUest symptoms are a change in the person's disposition, shght 
disorders of memory, and trivial lapses of various sorts. 

As the disease progresses the symptoms become more marked and 
fundamental, involving not only the intellectual but also the emotional 
and volitional phases of consciousness. Interest in the outside world 
begins to flag, attention to wander, perception to be incomplete and 
inaccurate, association of ideas to be slow, memory to weaken and judg- 
ment to be impaired. Memory of the most recent incidents is the first 
to be lost, of recent years next, and then of middle age so that the pa- 
tient may not recognize his own children or know, for example, that 
his wife is dead; finally the memory even of 3-outh is lost and the patient 
is to all intents and purposes a child, liis condition being an exaggeration 
and aggravation of that commonly known as "second childhood." 

Several forms of Senile Dementia exist, of which the most common 
is probably the simple or non-delusional type. Other forms are funda- 
mentally the same as the simple, but with certain superimposed symp- 
toms. Fairly early in this type it becomes unsafe for the patient to 
continue in business. Due to impairment of memory and judgment he 
is apt to lose his property. Soon his work is poorly done or neglected 
entirely. He becomes garrulous and annoys his associates with tiresome 
repetitions of childish reminiscences, continually wandering from one 
subject to another. His speech becomes incoherent and his sentences 



The Practice of Osteopathy 299 

fragmentary. He grows untidy and indifferent to the ordinary niceties 
and conventions of life. His appetite is either poor or voracious; in the 
latter case the weight may keep up fairly well. He may be either apathet- 
ic or turbulent. If the former, he seems stupid, indifferent, and sleepy. 
He is credulous, docile, and very suggestible. Patients of the turbu- 
lent type are restless and always moving about, either depressed or 
elated, giving unreasonable orders and then contradicting them. Sleep- 
ing poorly, they are apt to get up and wander about the house at night. 
In men, prostatic disease may cause a recrudescence of sexual feehng. 
Patients of either type eventually become filthy, soiling their clothing, 
etc. Even in well advanced cases, however, senile dements are often 
able to perform well certain habitual activities, such as signing their 
names, or playing certain games, such as checkers or dominoes. 

Conf usional Type. — Another form of Senile Dementia, which may 
in severe cases usher in the attack, but which usually, when present, 
is sequent to the simple form, of which it is a more severe grade, is the 
confusional. The additional symptoms of this type are probably due 
to defective ehmination and the consequent toxicity. Usually unsys- 
tematized delusions, and sometimes hallucinations are present. Ex- 
cept for a possible occasional period of remission the confusion is con- 
tinuous. It varies greatly in degree, now being mild and passive and 
again active, perhaps developing into delirium. Orientation as to both 
time and place may be lacking. Such patients may ask for dinner a few 
minutes after a meal, go to bed at noon, be unable to find their own room, 
or to recognize their own children. They are apt to be obstinate and 
peevish. Delusions vary in type but both these and the hallucinations 
are usually painful and, being referred to the patient's associates, 
give rise to the thought that they are trying to kill or otherwise harm him. 

Delusional Type. — A third type of Senile Dementia is the par- 
anoid form. Dements of this type, owing to delusions of persecution 
and auditory hallucinations are sensitive and suspicious. Such cases 
may sometimes show good orientation, apparently unclouded minds, 
and little evidence of senility, requiring careful study to differentiate 
the condition from true paranoia. A patient may, on account of hallu- 
cinations of taste and smell, refuse food in the behef that it is poisoned. 
Members of his family who are devotedly caring for him are suspected 
of designs on his money, and this suspicious attitude frequently leads 
to unjust wills. The delusions and suspicions may be entirely concealed 
from the family. Wealthy paranoid dements are peculiarly apt to be- 
come the prey of scheming adventuresses, particularly in case of the 



300 The Practice of Osteopathy 

above mentioned sexual recrudescence, and marry them. Opposition 
of the family is regarded as part of their general persecution or as due 
merelj^ to their desire to get the estate. Some patients merely appear odd, 
suspicious, untidy, peevish, and childish. Some have expansive delu- 
sions and exhibit the euphoria so frequently found in syphihtic dements. 

Senile Delirium. — A fourth type has been described by some 
psycliiatrists under the title of senile dehrium. This may appear as 
the initial form of the disease or as an acute attack in one of the above 
forms. It is characterized by great incoherence and restlessness, en- 
tire absence of orientation, and numerous rapidly changing delusions 
and hallucinations, the condition resembhng dehrium tremens. It 
is probably due to some somatic cause, such as nephritis, pneumonia, 
or cystitis, which is often fatal. 

Complications may arise in Senile Dementia, such as apoplectic 
strokes, hemiplegia, epileptiform seizures and aphasias. 

Prognosis. — It is evident from the pathology of the conditions 
that the prognosis is not at all good when the disease is well advanced. 
It is a chronic disease and usually progressive until death, which is due to 
one of the complications, malnutrition, or especially pneumonia. How- 
ever, many cases have shown improvement, and in incipient stages re- 
covery. A cure of advanced cases being impossible, the important 
consideration is prevention or arrest in its incipiency. 

It is evident that this can be done only by preventing, or removing 
as far as possible, the predisposing causes. A glance at the list of these 
shows that much depends upon the cooperation of the patient by regulat- 
ing his habits of Ufe. Physical and mental overstrain must be avoided, 
deleterious habits, such as the use of intoxicants or narcotics given up. 
Much can be done by osteopathy to eliminate the effects of these upon 
the organism. Cardiovascular and renal symptoms are very important 
and should be watched for in order that early treatment may check the 
process initiated. To this end the patient's habits and diet must be reg- 
ulated and treatment instituted to relieve toxicity and promote ehmina- 
tion. Lesions must be corrected, special attention being given to the 
lower dorsal that affect the kidneys, the upper dorsal that affect blood 
pressure, and both the upper cervical and upper dorsal that affect the 
blood supply and nutrition of the brain. 

Arteriosclerotic Dementia. — This is a mental enfeeblement 
arising sometimes in the fourth, but chiefly in the fifth, decade of hfe, 
and associated with symptoms of arterial hardening. 

The cause is arteriosclerosis, which may be second aiy to some form 



The Practice of Osteopathy 301 

of nephritis. The arterial hardening may be general or may be con- 
fined to the arteries of the cerebrum. It is hkely that the arterioles 
supplying the cortical cells are especially involved in an atheromatous 
condition. The disease is organic, chronic and progressive. Hemor- 
rhage, embohsm, or thrombosis may occur, producing focal lesions and 
areas of softening, with hemiplegia, aphasia, etc. 

The earhest symptoms may be headaches and dizziness. The 
blood pressure is usually found to be high but not invariably. An athero- 
matosis may be present in some one of the palpable peripheral arteries, 
such as the radials. Further symptoms on the physical side are quick 
fatigue, loss of energy, numbness and paresthesias of the extremities, 
and somnolence in the daytime or perhaps insomnia at night. Strokes 
may occur, usually sKght and temporary, probably due to spasm in a 
degenerating artery or perhaps to serous effusion. Toxic symptoms ap- 
pear, due to disorder in kidneys, Kver, and other organs. Epileptiform 
seizures are possible. Mentally the patient shows impairment of mem- 
ory, and perhaps some confusion and hallucinations. Rarely stupor 
occurs. He may be agitated and irritable or melancholy and depressed. 
Suspicious and persecutory ideas of the paranoid type may appear; 
also hypochondriacal ideas. 

Osteopathic Theory. — In these psychoses of the older years of 
life the termination is usually dementia, which means mental enfeeble- 
ment, and which results from degenerative changes in the brain substance. 
As has been shown it is largely a nutritional question and the nutritional 
condition varies tremendously in different elderly people ; it is well known 
that many old people preserve their brain powers fairly well to the end; 
on the other hand others fail relatively early, some even in the fifties; 
these cases of earlier failure are referred to as the ''presenile type. " The 
osteopathic conception would be to find out the source productive of the 
nutritional disorder and correct it at the very outset, therefore making 
it quite possible to prevent the disease process from taking place. The 
prognosis then in the earher stages is very good. 

Remarks by Dr. Hildreth 

While many cooperating factors may be found in the causation 
of the mental disorder of elderly people, our experience shows there is 
always very definite disturbance of nutrition and the nutritional cen- 
ters. We find chief physical interference between the 3d and 8th dor- 
sal vertebrae, most definite as a rule at the 4th, 5th and 6th; with the 
corresponding ribs on the right side. Contributing causes may be found 



302 The Practice of Osteopathy 

in other areas, associated with the disturbances of the heart and circu- 
lation and of the kidney. In the cardio circulatory disorders we find ab- 
normal spinal conditions in the upper dorsal region and especialty the 
5th rib on the left side. In the kidney disorders we find the lesions usu- 
ally at the 10th, 11th and 12th dorsal. The above mentioned areas 
in general represent the centers of control of the splanchnic nerves and 
therefore the important processes of digestion, metabolism and assimila- 
tion. Specific treatment applied to these points is verj^ helpful and re- 
sults in marked improvement and indeed in relieving the patient's symp- 
toms completely when in the earlier stages of the disease. 



The Practice of Osteopathy 303 

DEFECTIVE CHILDREN 

By Raymond W. Bailey 

It is our purpose here to impress on osteopaths the almost unlim- 
ited possibiHties in the study and treatment of mental conditions of chil- 
dren, which heretofore have been considered hopeless. Osteopathy has 
demonstrated that it has much to offer to this class of defectives but the 
profession has not thoroughly appreciated its great possibiHties. It has 
been the custom to send these children to institutions where they have 
received care with some attempt toward education but with absolutely 
no effort being made through physical treatment to overcome their 
debiht3^ We shall show that the osteopathic lesion is of prime import- 
ance in these cases, and that we have been slow to reahze the efficacy 
of osteopathic treatment for such seemingly hopeless children. We can- 
not emphasize too strongly the importance of accepting and treating 
these cases wherever possible. 

The mental diseases are considered under two general heads: (1) 
Inherited, and (2) Acquired Tendencies. 

1. Inherited Tendencies. — In this class are those cases arising 
from poor endowment of the protoplasmic structure through lowered 
vitality of the parents or other progenitors. These taints may come 
from either parent, or both, and may exist in the offspring from some 
preceding generation. Such diseases are constitutional and are amen- 
able to supporting treatment in direct proportion to the amount of 
endowed energy inherent in any given organism. 

Of the inherited tendencies, we have two kinds: 

1. Congenital Diseases, (a) From any influence of an inherited 
nature not directly acting on the environment of the parent while the 
fetus is in utero, and 

(b) From any influence which directly affects the development of 
the ovum through imperfect fertilization coming through either parent 
or both. 

2. General Impairment. — This condition exists (a) Where a 
similar defect has existed in foregoing generations and is strictly hered- 
itary; 

(b) Where general vitality is diminished from such causes as neuro- 
pathic parents, or where there have existed constitutional defects, such as 
tuberculosis, syphilis, epileps}^, alcoholism, abuse, overwork, strain, 



304 The Practice of Osteopathy 

acute inflammatory diseases, and poor health of the mother during ges- 
tation ; also consanguinity. 

(c) Premature birth tends to impairment physically and mentally 
of growth of organism and frequently leaves its manifestations of ma- 
rasmus, rachitis and other nutritional disturbances. 

(d) Prolonged labor may leave its mark on the child where more 
or less asphyxia has occurred resulting in obstruction to cerebral cir- 
culation. 

Causes acting after birth to the already impaired germ cell and re- 
sulting in many of the afflictions of early life, both mentally and phys- 
ically, are 

1. Traumatism. 

2. Convulsions. 

3. Rachitis. 

4. Infectious fevers. 

5. Meningitis. 

All of these seriously affect the metabolism within the newly-born, 
a process which is begun, doubtless with difficulty, and susceptible to 
easy derangement, and the same effect magnified with growth into its 
subsequent mental and physical deformity. 

2. The Acquired Tendency. — In this the second great class 
are those conditions arising subsequent to conception where germ plasm 
is healthy but growth is arrested by some external factor either intra- 
or extra-uterine. Thus the acquired tendency may be given to the 
fetus in utero and not be considered congenital as in case of injury affect- 
ing health and growth of otherwise healthy conception. In short, the 
acquired has its beginning at conception or subsequent to it while the 
congenital is previous to conception or already inherent in the germ plasm 
leading to conception. 

Any influence which retards the 

1. Inherent capacity of cell for growth or, 

2. Adequate blood supply either in quantity or quality results in 
enfeebled offspring and these causes are enhanced by 

(a) Traumatism or Injury 

(b) Drink or Abuse 

(c) Dirt or Unhygienic surroundings 

(d) Depravity or Ignorance 

Factors entering into acquired tendencies affecting offspring direct 
are divided into three classes, those: 



The Practice of Osteopathy 3C5 

I. Before birth such as 

(a) Abnormal condition of mother's health during preg- 
nancy as in disease of any nature, mental or physical or 

(b) Injury to fetus direct by blow, fall of parent, oi 
instrument. 

1 1 . During Birth from : 

(a) Abnormal labor from any cause. 

(b) Primogeniture. 

(c) Premature birth. 
III. After Birth. 

(a) Traumatism. 

(b) Toxic causes such as scarlet fever, whooping cough, 
meningitis, measles, mumps and exanthemata. 

(c) Convulsions. 

(d) Nutritional disturbances. 

Consanguinity or intermarrjdng of blood relations, or in-breeding 
results in : 

1. InstabiKty of the nervous system. 

2. Intensifying of constitutional defects. 

3. Decrease in size of offspring. 

4. Predisposition to disease through lowered vitality. 

5. Impairment of reproductive function. 

Immediate consanguinous offspring may manifest a high degree of 
intellectual or physical attainment but successive processes tend to 
neurotic types and are prone to physical weaknesses and insanity. This 
practice is found among Quakers and Jewish peoples, inhabitants of the 
Islands north of Scotland, in isolated rural localities, and among African 
tribes. 

Mental Deficiency in Children 

Synonyms. — Amentia ; f eeble-mindedness. 
There are three grades of amentia: 

1. Morons: those whose mental age corresponds closely to 
their chronological age or is nearly normal. 

2. Imbeciles: those in whom there is a wide disparity between 
the mental age; and the chronological age. 

3. Idiots: the lowest form of arrested mentality or those whom 
it is impossible to teach. 

Definition. — Mental deficiency is a pathological stage in which 
the mind has failed to attain normal development. 



306 The Practice of Osteopathy 

Various degrees of intelligence or mental capacity in man lie 
betweeen: 

(1) Genius such as Bacon, Newton, Plato, Galileo, Shakespeare. 

(2) Lesser Ability but still conspicuous in development such as 
our great leaders in science, literature, reform and the arts and medicine, 
furthering, each their respective causes. These merge easily into 

(3) Average mass of mankind. 

(4) Dullards or those of inferior intelUgence. 

(5) Feeble minded, merging imperceptibly into 

(6) Imbeciles and by insensible gradation into 

(7) Idiots and gross idiots. 

The mentally defective is wholly incapable at maturity of adapting 
himself to his environment or local conditions in order to maintain ex- 
istence independent of any external support. 

Dementia is a disease of the mind or that which was once possessed, 
and by some neuronic disturbance is lost totally or partially. 

Insanity is a disturbance of neuronic function which may or may 
not end in degeneration of brain tissue. 

Physiology. — The normal brain begins its development shortly 
after fertiUzation of the germ cell, by the expansion of the anterior end of 
the rudimentary spinal cord into four primary cerebral vesicles. These 
develop into a series of elaborate infoldings, each with multiple cells 
around them. At or about the sixth month of fetal Hfe this embryonic 
brain assumes the shape of the adult brain, minus the secondary fissures 
and convolutions which are characteristic of full development. 

At birth there are sometimes many convolutions and the brain weighs 
from 280 to 330 grams. Growth is then rapid and at six months it weighs 
from 560 to 680 grams; 

At one year, 750 grams. It continues to increase until 

At 12 to 14 years it weighs 1150 grams in the female, and 1300 in the 
male ; 

At 20 to 21 years the weight is 1244 grams in the female and 1374 
in the male. 

Growth is slow from this time until at 25 to 35 years the average 
weight of the brain is 1269 grams (45 oz.) in the female, 1421 grams 
(50 oz.) in the male. 

This growth of the brain is due, first to the rapid multiplication of 
nerve cells and, secondly, to the individual enlargement of each nerve 
cell. These cells arise from the floor of the four primary vesicles and are 
each similar to its fellow. They finally show differences in feature and 



The Practice of Osteopathy 307 

become characteristic in size and shape which process continues through- 
out Hfe. This process of differentiation of nerve cells results in the pe- 
culiar laminated appearance of the brain cortex. At the period of lam- 
ination, the nerve cells throw out delicate processes which pursue definite 
directions throughout the brain mass constituting a system of associa- 
tion fibers which link together in a most complicated manner all parts 
of the brain, and are called the association fibers of Flechsig. Projec- 
tions from these cells form the various pathways by which the brain is 
connected to the various parts of the body. 

Nerve cells in the different parts of the brain mature at different 
periods, those areas which have to do with the highest intellectual func- 
tions, viz., the frontal and parietal regions, maturing last. 

At the seventh month of intra-uterine life the brain cell is a small 
round type of neuroblast, undifferentiated, lying in a matrix. The cells 
increase in size until about the second week (extra-uterine) of life, tiny 
processes begin to develop. At the third to fifth year these cells are 
mature and possess axons, dendrons and geminules. These communi- 
cate, forming the above-named association system conveying impulses 
to and from all parts of the cerebrospinal system. They multiply and 
elaborate after puberty into a compHcated system up into middle hfe 
after which growth ceases and they slowly diminish. 

Greatest Growth is between the first appearance of the primitive 
brain and the end of the sixth month of Hfe (extra-uterine) , hence it is 
during this period that any adverse conditions relative to development 
of nerve cells may cause the greatest damage. 

Mind and Brain. — Whatever may be the connection between these 
two, we know that the former develops with the growth of brain cells 
and fails with their decay. Amentia is associated with the incomplete 
development of brain cells and Dementia is coincident with their de- 
generation and death. 

Patliology — Brain. — Structural abnormahty of the brain tissue 
may exist without variation of mentality or defect. Early observers 
gave these gross defects as a cause for amentia. However, it has been 
demonstrated beyond doubt by microscopic examination of cerebral 
neurosis that cellular changes occur and that imperfect and arrested 
development exists and is an essential basis of amentia. 

Histology — Blood Cells. — Cortical blood cells in the ament are 

1. Xuinciiciilly fewer. 

2. Irregular in arrangement. 

3. Imperfectly developed. 



308 The Practice of Osteopathy 

4. Microscope reveals changes proportionate to the deficiency dur- 
ing Hfe. 

Blood-vessels in Amentia show no marked changes from those 
of the normal brain. Hyahne degeneration may be present; also pig- 
mentation. These conditions are not constant in amentia hence cannot 
be considered causal. 

Neuroglia in Amentia. — Sclerosis and hj^pertrophy occur in a 
large proportion of cases. This is diffuse throughout the brain, with 
here and there certain circumscribed areas forming nodules. 

Nerve Fibres of Cortex in Amentia. — Association system fibres 
are always diminished in number and not sO comphcated. 

Clinical Varieties of Amentia. — There are two varieties of amen- 
tia and conventionally^ for sake of study we must arrange them into 
those from 

(1) Congenital causes and (2) acquired causes. 
Among those which arise from congenital causes we have the micro- 
cephalous and MongoHan types. In both cases there exist constitutional 
taints through successive or immediately forgoing generations of such 
diseases as syphihs, tuberculosis, epilepsy, and acute alcohohsm affecting 
proper collaboration of germ cells previous to fertihzation and hence 
impaired germinal endowment through a weakened nervous system. 
Those arising from acquired causes are from injury to mother or 
fetus. 

Microceplialus. — A person whose skull measures less than seven- 
teen inches in its greatest circumference. This class comprises less 
than 10% of all aments. 

Cause. — The type is neither a freak reversion of the species to a 
lower grade of development nor accidental, but due to an inherited blight 
on the nervous system arising from constitutional disease, alcoholic and 
sexual excesses, consanguinous unions and too numerous latter-life preg- 
nancies in undermined health states. They come entirely from neuro- 
pathic stock and their brothers and sisters are degenerates. Many dwarfs 
exhibit this type. 

Cliaracteristics of Microceplialy. — (1) Circumference of skull 
diminished; (2) Brain smaller; (3) Stature small (5 feet); (4) Rarely 
live to advanced age; (5) Die of tuberculosis; (6) Mostly imbeciles and 
idiots (few morons). 

They have their sensory impressions intact and are generally vi- 
vacious and muscularly active, even restless. They have good sight 
and hearing and are highly initiative but have not the ability to any sus- 



The Practice of Osteopathy 309 

tained effort. They are actively observant and the majority are affec- 
tionate and well behaved. Some are unsteady in walking, others are 
helpless, and about one-half are subject to epileptic fits. 

Mongolian Amentia (Mongolism). — This type (Kalunk or Tartar 
variety) received its name from Dr. J. Langdon Down from their facial 
resemblance to members of the MongoHan race. They number about 
5% of all aments including the semi-mongols who have only a few of 
the characteristics of this type. 

Cause. — Eleven out of twenty-five are from syphilitic origin. Gland- 
ular or nutritional defects are suggested as a cause. They will show 
negative Wassermann test and positive tubercuHn tests. Uterine ex- 
haustion and ill-health of mother during gestation are factors suspected 
of entering into this condition. The latter-born of large famihes are 
frequently affected. 

Pathology of Mongolian Idiocy. — The brain of the Mongolian 
anient is considerably under-sized and has less convolutions and is more 
shallow. The pons, medulla, and cerebellum are about half the size of 
ordinary feeble minded types. The cells by microscopic examination 
show an immature condition. This lack of brain development results 
in deficient expansion of base of skull, hence the characteristic physiog- 
nomy. There is no glandular abnormality. 

Description of the Mongol Type. — This type is distinguished by 
characteristics of skull, eyes and tongue and is usually observed at birth 

1. The skull (Brachycephalous) is rounded and diminished in size 
particularly through the antero-posterior diameter. The face is flat- 
tened, there being no recession of frontal and supra-occipital regions. 

Eyes. — The palpebral fissures are narrow and slope obHquely down- 
ward and inward. Lids inflamed. 

Tongue protrudes, is large and marked by large papillae and 
scored by transverse fissures due probably to tongue sucking, predis- 
posing to inflammation of the mucous membranes. 

Ears are small and round and have poorly developed and irregular 
lobules. 

Nose is short and flat and has triangular nostrils. 

Teeth are soft and ill formed and tend to decay. 

Hair is usually scanty and wiry and very dry. 

Cheeks arc flushed. Palate is high and narrow and mouth is open, 
and lips are cracked. Adenoids exist in all cases. 



310 The Practice of Osteopathy 

Hands and Feet are broad and clumsy. Flat foot and knock- 
I noes are common. Skin is rough, coarse and dry. 

Abdomen is large and mushy. UmbiUcal hernia often present 

Circulation is rarely good, causing blueness and coldness of ex- 
tremities, with sores and chilblains. Heart lesions are frequent. Les- 
ions of a chronic inflammatory nature in respirator}'- and digestive tracts 
exist. Nasal and bronchial catarrh and diarrhea are common. Mon- 
gols die early (about 14 years) usually of phthisis. 

Available statistics show the various types and variations of these 
conditions in great detail; however, the above will enable the reader to 
classify and properly diagnose in given cases. It is not the writer's 
intention to portray here what is easily a treatise bj^ itself. 

Osteopatliic Consideration of Amentia. — During a period of 
five years, observation of the various types has led me to believe that 
much can be done to correct circulation to cerebral structure with con- 
sequent development of brain tissue and function, where discoverable 
trauma exists. From all available sources there is traumatic interfer- 
ence in from 15 to 45% of these cases, according to different authors. 
Where history involves constitutional findings (syphilis, tubercular, 
glandular and chronic alcohoUsm) I have treated them with the intent 
of relieving only until the next phase of the condition would appear. 
Where trauma alone exists and the family history is good, I know the 
case is in the field of osteopathy alone, and can be developed to a degree 
limited only by the intelhgent care of those having the case in charge. 
Especial attention should be given to disciphne, housing, sanitation, 
personal hygiene and general environment. 

Lesions. — Atlas, generally rotated. Rarely posterior but fre- 
quently resting beneath a posterior occiput. Lateral mass on the pos- 
teriorly resting portion of misplaced atlas will become interlocked with 
transverse process of axis in a few instances, combining the amentia with 
a progressive inflammatory tendency to the middle ear which by suc- 
cessive abscesses ultimately destroys structure and function; possibly 
traumatic epilepsy, and surely catarrhal inflammations in all mucous 
membranes of the head. 

Many bony and ligamentous irregularities exist in the various types 
of mental defective where the cause is inherited weakness, nutritional 
diseases or kindred sources. Spinal luxations exist singly and in series, 
causing various palsies, spastic muscles, and deformit}'. Postural de- 
fects, particularly of ribs and costal cartilages cause functional disturb- 
ance throughout the thorax and abdomen. 



The Practice of Osteopathy 311 

Treatment. — Invariably the care of aments entails wisdom of 
procedure. Reconstruction is the prime object in every instance, hence 
time and number of treatments must not be considered. Treat to cor- 
rect structure; teach as far as possible; train always. 

Deft and intelKgently applied technique are certainly required in 
the correction of these cervical lesions. Treatment should be given thrice 
weekly (never less than twice for progress) with definitely established 
mental tests before, to discern the mental level, and at succeeding per- 
iods of three months each, noting progress, if any. The Binet-Simon 
scale or some other available mental test should always be made and 
record carefully kept of each case for your own benefit as well as the 
patient's. After six months, if no appreciable gain is shown treatment is 
discontinuted and the case must be cared for in another manner as be- 
yond your special field of effort. Usually it is apparent by the end of 
the third month if anything can be done to improve the mentality. The 
physical advantages, in some cases wa'rrant continued treatment where 
there is no appreciable mental gain. Institutional care of these types is 
the only practical means of handling them properly from an osteopathic 
standpoint, as it requires some one properly equipped to make your tests 
and keep your record; — it is sufficient for the doctor to do the work de- 
manded. They can thus be classified and progress systematically shown. 
The higher grades must be taught and though self dependence may never 
be attained they can in many cases by training be capable of useful pur- 
suits and quite frequently remunerative work. It makes for happi- 
ness at least to keep them busy and forestalls the mischief that would 
otherwise result. Even imbeciles can help in routine work of an insti- 
tution or home, and idiots may, by training, gain some power of self help 
and cleanHness. Training depends on the individual capacity for such 
in each case — his habits, and general character of his propensities. Pre- 
vention of their marriage should be positive and for prevention of their 
propagation this and their sterihzation by operation are the only two 
measures at hand. Sterilization, however, is repugnant to some elements 
of society and could be abused, hence the segregation of aments would 
appear to be our only solution at present. The ultimate intention of 
treating any case is to use any measure tending to stabiHze the nervous 
system. Corrective effort alone is not sufficient but these osteopathic 
endeavors in conjunction with proper discipline, good food, regular rest 
and personal hygiene both mental and physical and a scrutinizing re- 
striction tending to any kind of excess is rendering the osteopathic pro- 
cedure in such cases rapidly indispensable for the treatment of amentia. 



312 The Practice of Osteopathy 

POST-OPERATIVE TREATMENT 

By George A. Still 

At the convention of the American Osteopathic Association held in 
BovSton in 1918, I gave a short talk on the above subject, and during the 
day after I had given the lecture, two women and one man, graduate 
osteopaths, asked me if I really meant to convey the impression that we 
actually gave osteopathic treatments to recent surgical cases. I do not 
know whether I convinced them or not, but I do know that they con- 
vinced me that there are people practicing osteopathy who have abso- 
lutely no concept of its merits and underlying principles. 

To my surprise I have found that a great many osteopaths who con- 
sider themselves absolutely "pure" are just a bit startled at the thought 
of handhng post-operative compUcations by treatment. These are in- 
variably fellows who have had most of their experience in office work, 
and who do not come in contact with acute cases. Still it is difficult 
to conceive how a man can believe that osteopathy is specific for certain 
diseased conditions and not for others. As a matter of fact osteopathic 
treatment has not proved itself more satisfactory in any field of thera- 
peutics than it has in post-operative conditions. 

The common post-operative conditions are pneumonia, pleurisy, 
backache and headache, nephritis, vomiting, neuritis, phlebitis. 

Taking up these subjects and discussing the least serious first we would 
of necessity discuss pneumonia last, as it is the most serious, and is less 
influenced by other conditions. It will also serve to illustrate many of 
the details in treatment. 

We will therefore briefly take up the other conditions and then dis- 
juss pneumonia more fully. 

Vomiting 

We believe there is no question that a good part of the prevention of 
anesthetic vomiting is in the preparation of the patient, including a 
good cleaning out of the bowels without debihtating cathartics. In 
other words, the vomiting is increased if the alimentary tract is loaded, 
or if on the other hand it has been irritated to the extent of losing its tone. 
Combining a careful preparation with a straight ether anesthesia and 
osteopathic treatment to the neck and splanchnics we have been able 
to eliminate any serious post-operative nausea. I do not recall a case 
in the last few years that vomited on the following day unless the con- 



The Practice of Osteopathy 313 

dition for which they were operated was one that essentially in itself 
would cause vomiting; for instance if the patient had peritonitis and 
had been vomiting due to the toxic ileus. They might even vomit after 
the abdomen had been opened. This could hardly be called "post-op- 
erative" vomiting. 

The improvement in our records in post-operative vomiting is in 
proportion to our increased faith and use of the osteopathic treatment. 
Time and again patients have told us that they had taken anesthetics 
before and were sick from three to five days and even a week. Invar- 
iably we have been able to surprise these patients by the fact that they 
were sick less than a day. 

The usual treatment with bismuth sub-nitrate, cerium oxylate, 
sour wine and the other usual remedies were not used in any case or in 
any amount. No drugs whatever were employed. 

Backache and Headache 

There is practically no difference in the post-operative headache 
■and the office headache. There is of course the usual multipHcity of 
causes, and as a matter of fact in this condition treatment can more 
nearly approach the ordinary office treatment, and the results are about 
the same. As for backache, we find that speed of operating and not 
keeping the patient under the ether too long has a marked influence. 
Also we have a four inch Seely mattress on the operating table which 
helps some. Treatment does the rest and does it effectively. For this 
compHcation even the ordinary nurse knows enough to give a treatment 
of some sort. 

Neuritis 

Nine times out of ten the post-operative neuritis is really a local 
osseous lesion, a shpped innominate, rib, vertebra, clavicle, biceps ten- 
don or something of the sort, and responds quickly to a specific treat- 
ment. 

Phlebitis 

This compHcation usually comes on quite late after an operation 
and at first it is sometimes hard to differentiate it from a neuritis. Ab- 
solute rest of the involved part with lower spinal treatment gives relief, 
but under no circumstances should the affected part be freely moved 
while there is active inflammation. The reason for treatment of the 
lower spinal area is that practically always one of the saphenous veins is 
involved. 



314 The Practice of Osteopathy 

Nephritis 

This complication is to a very big extent eliminated by a careful' 
urinalysis prior to the operation, and careful preliminary treatment in 
indicated cases, and in other cases the postponement or if necessary com- 
pletely elimination of the operation where it is not a case of life and death. 
Where the condition does appear we have found it the hardest of the 
post-operative complications to control. Indeed it is the only one that 
we have not found very easy to manage. 

We do not vary the treatment for a post-operative nephritis from 
what we would use in any ordinary case of nephritis. We have observed 
treatment of this condition in many cases under medical management, 
and wliile we are satisfied with the osteopathic treatment compara- 
tively we are not yet satisfied that we have it developed to its greatest 
efficiency. 

Pleurisy 

This condition in nearly every instance can be corrected with one or 
two treatments of a twisted rib unless it is the pleurisy of a beginning 
pneumonia. As far as the pain is concerned the simpler type hurts as 
much as the one that is going to develop a real complication. For this 
reason relief obtained by a single treatment often seems Httle short of 
miraculous to the patient. 

Pneumonia 

When I took charge of the surgical work at Kirksville, osteopathy 
was not used in post-surgical treatment. Post-operative vomiting was 
treated medically, as were other post-operative conditions, including 
pneumonia. Cases of a real major surgical nature rarely got an osteo- 
pathic treatment. 

The idea seemed to be that osteopathic post-operative treatment 
had to be along the same fines as it would be for such an illness as lumbago, 
brachial neuritis, or ordinary pneumonia, and other non-surgical con- 
ditions where the patient could be placed for giving a treatment in a 
position that was not permissible following an operation, as it would 
work great harm to the wound. 

It seemed to me that if osteopathy was effective in a case of ordi- 
nary non-surgical pneumonia, it should certainly be good for a case df 
pneumonia that was post-operative and that all we had to do to handle 
the condition was to apply a new technique of treatment that could be 
used on a patient who had a surgical wound. All we had to do was to so 



The Practice of Osteopathy 315 

manipulate the spine that we would get the results locally, and yet handle 
it in such a manner as not to affect the wound. 

Many laymen, and even some physicians of our own school, express 
surprise at the suggestion that we do much osteopathic work in the 
after care of surgical patients. But the fact is we have worked it out so 
that now, except for pain, during the immediate after effects of the op- 
eration drugs are absolutely not used in our hospital for any of the post- 
operative complications. The opiate immediately following the opera- 
tion, is really a follow up of the anesthetic, and we use that as rarely as 
possible. Needless to say, there are cases such as un-united fractures, 
extensive adhesions, etc., where the emergency conditions positively call 
for some relief of the pain for a short while, but that is the only condition 
that we cannot control with mechanical treatment. 

I am very glad that I had the confidence to give this an early trial 
^nd a thorough trial, without being afraid to leave off the drugs. The 
big field, however, where osteopathic treatment has won the most im- 
pressive success and proved itself a most absolute specific, is in the field 
of post-operative pneumonia with which I am proud to announce a one 
hundred per cent, success for combined osteopathic treatment in my 
fourteen years continuous surgical work. Not to have lost a single 
case is partly due to luck. In other words, with any series of serious 
cases, it is impossible but that there be some fatality finally. 

Post-operative cases have one advantage along with their disad- 
vantage. While they have the shock of the operation to contend with, 
and the weakened condition from the disease for which they were op- 
erated, still except in extreme emergency they would not have been op- . 
erated on unless they had a good heart and good kidneys and a good 
blood pressure, so that in cases in which we are most concerned in com- 
batting pneumonia, we usually start with a patient who has those or- 
gans in a healthy condition. 

First Post-operative Pneumonia Cases Treated Osteopath- 
Ically. — At the Chicago Convention in 1911, I reported the first post- 
operative pneumonia cases that had been treated osteopathically. I 
believe at that time that there had been only three cases. At that 
meeting I mentioned the fact that some of the doctors and some of the 
internes who treated those cases felt sure that they were not treating 
them properly because they could not get away from the idea that pneu- 
monia needed strychnin and other drugs. One of these cases got well 
in three days from the developed lobar pneumonia symptoms. The 
results were so miraculous that the young man treating it began to doubt 



316 The Practice of Osteopathy 

whether it could have been pneumonia. He could not understand how 
he, a senior student, could overcome this dreaded disease by merely- 
working on the spine. He could not believe that osteopathy, a science 
that he had been able to learn himself, so easily could cure a condition 
that he had thought must be almost necessarily fatal. 

One of the weaknesses of osteopathy is the fact that there is no 
mysticism about it. It is so simple that any person with ordinar}^ in- 
telligence can learn to use it, and yet it is so simple that it takes an un- 
usual intelligence to be able to grasp the fact that it is the therapeutic 
discovery of the age. Many, many times I have had young internes 
and students cure genuine lobar pneumonia and do it with such obvious 
ease that it caused them to wonder, in a way, if it really could be pneu- 
monia. It is bred in our very tissues to look for some mysticism, some- 
thing impossible to understand, something supernatural, something 
connected with the Unknown associated with the treatment of disease 
and accordingly it is just human nature to find it difficult to believe, 
even when we see it, that a simple method of treatment can actually 
effect a cure. 

Real pneumonia, as we understand it, is a consohdation of the lung 
tissues characterized by fibrosanguinous exudate into the pulmonary 
tissues and spaces, associated with one or more particular germs as ex- 
citing factors and proved by the physical tests and the character of the 
expectoration. How many cases have been cured that had not entered 
consolidation I do not know because up until the time of actual consolida- 
tion there may be a question as to whether or not they would have had 
pneumonia. I know that many cases with marked symptoms of pneu- 
monia have failed to develop under treatment or the case has been aborted . 

Pneumonia lacks a great deal of being a seK limited disease. The 
number of cases with beginning s5Tiiptoms that fail to develop is too 
great to be ascribed to coincidence. Of course I know that some of 
these might have been only pleuritis, some only neuritis, etc. How- 
ever, in giving the statistics of pneumonia cures we will give only those 
in which pneumonia developed and showed a hardening or consohda- 
tion of the lung tissue. In these cases there can be no argument as to 
whether there was pneumonia. 

When we have an acute condition associated with the sjanptoms of 
consolidation, we can hardly be confused as to the diagnosis. We may 
make a mistake in our physical findings, but hardly after a Httle ex- 
perience, and certainly when we are sure of the physical findings there 
will be no trouble in naming the disease. 



The Peactice of Osteopathy 317 

The Clinical Findings. — Post-operative pneumonia is a Kttle 
different from the common pneumonia. It always comes on a little more 
insidiously. One has to watch for post-operative pneumonia more close- 
ly than he would for the attack that we may meet in ordinary practice. 
A patient may have considerable pain from his wound, may have some 
pain in the back from the position he is in; there may be headache, and 
an upset feeUng from ether; and the pain comes in the chest. All 
these symptoms are forerunners of pneumonia, but the pain in the chest 
is not noticed until it gets quite severe. In other words,there are other 
things to annoy the patient as well as the attendant, and at first, this 
condition does not cause complaint. A strong and healthy individual 
who feels a pain in his pleura, which is the forerunner of pneumonia, 
knows it at once, because that is the only distress he has. His entire 
attention is attracted and he asks for a physician's help. But in the post- 
operative case, the physician has to keep a look out in order to prevent 
a case from getting well under way before it is recognized. 

As an example of this I had a case of a man who was with a party 
driving an automobile and they tried to cross the railraod track in front 
of a train. This patient I speak of was one of the survivors. He had 
a fracture of the femur, fracture of the skull, fracture of three ribs, and 
otherwise more or less bruised up. Naturally the preliminary work con- 
sisted in getting the ribs and legs attended to as well as possible and 
looking out for cerebral hemorrhage or meningitis. 

This patient developed consolidation in both lungs in spite of regu- 
lar treatment, and it precipitated on him very rapidly, partly masked by 
the disturbed breathing from other sources of irritation. We put him 
on hourly treatment, but after a few hours his condition from the in- 
juries and the pneumonia was such that his wife asked us not to treat 
him any more. She put it this way, that she knew he would die in spite 
of all that could be done and as long as he was going to die he might 
as well die easy. Every time he was treated it had the effect of bring- 
ing him out of his stupor, and he would complain, and she thought it 
would be a kind act to let him slide off into the next world uncomplaining. 

Pneumonia in a case of this sort cannot be handled with kid gloves 
if we wish to save the patient. We must give firm, strong treatment. 
Light treatment in this condition will do no good. Indeed Hght treat- 
ments in any sort of pneumonia are of httle avail. Many times I have 
changed internes in a pneumonic case that was not responding and the 
results were immediate. That is, the turn for the better was obvious 
from the beginning of the good strong treatment. 



318 The Practice of Osteopathy 

The case above mentioned was treated a good part of each hour for 
twelve hours. He had no strychnin, no oxygen, nothing but treat- 
ments, but he got well and is now living, and aside from a limp has no 
evidence of either his injury or his illness. 

Some cases, in private practice, may get well on a treatment a day, 
but I would hate to handle the kind of cases we get in that manner. 
I have had severe cases, especially hemorrhagic cases, where the treat- 
ment was almost continuous for hours preceding the crisis. Of course, 
after the crisis we can ease up. On the other hand, it is not infrequent 
that a few good strong early treatments, given at the beginning of a case 
absolutely stop it. I have seen cases where a consoHdation area of the 
apex of the lower right lobe as large as the palm was easily outUned, and 
this together with the chnical symptoms would be cleared up in two or 
three days. 

There is no possible medical method by which this can be done. 
Medical authorities agree that under their treatment pneumonia runs an 
unshortened course; in other words, a course in the individual case that 
has not been affected by the medication. Medically, even where the 
crisis occurs early, the consolidation persists for some time, but I have 
seen it cleared up time and again under osteopathic treatment in the 
length of time that could have been brought about only by osteopathic 
treatment. 

I have previously called attention to the fact that many of the 
medical text books on physical diagnosis mention a point that is a very 
practical and very plain demonstration of the efiiciencj^ of osteopathy 
in puhnonary conditions. These books only mention this fact without 
pointing any moral or drawing any conclusions. The point is this: 
that frequently when a professor is having a class or a section of a class 
examining a case of pneumonia, they will outhne the size of the consoHda- 
tion at the beginning, the instructor marking it off when he makes 
the first examination; then after the students have examined it, by per- 
cussion, palpation, etc., possibly a dozen or twenty of them, the later 
students will find that the area has shrunken perhaps an inch. This 
fact has been frequently noted. It is said, indeed, that if careful ex- 
amination is made it will alwaj^s be noted. 

How Manipulative Treatment Benefits 

Doubtless this proved that accidental manipulations of the ribs 
helps clear up the congestion about the real consohdation and reduces 
some of the dull area. Very likely this explains some of the cases of 



The Practice op Osteopathy 319 

partial or real results from spondylotherapy. Naturally, scientific os- 
teopathic treatment would necessarily magnify such results very much. 

It is a great wonder with the obvious failure of medical treatment 
in pneumonia, that at least some crude from of manipulative treatment 
has not been devised by those practitioners. We have already men- 
tioned that the treatment of post-operative cases varies mainly in the 
manner of applying it. In other words, when we raise the ribs we keep 
the patient on his back, in treating the spinal centers we treat with pa- 
tient on his back, and the physician who has no grip in his hands will not 
be able to treat a post-operative pneumonia to any advantage. 

In these cases one has to get at the patient's back by reaching under 
and the weight of the patient helps to give the treatment, but a strong 
grip is necessary. It is much safer for the wound to handle the patient 
in this way but not infrequently beginners wear their knuckles pretty 
nearly off before they get the finer technique; after which it is easy. 
In raising the ribs there is no more difficulty in treating in this position 
than there is with a patient who can sit up or turn from side to side and 
in some cases a patient can, of course, be partially turned. 

Theory is all right but in these cases practice has been added to it 
in something over three hundred cases treated in this manner, and in 
this manner only. I have had no case die. None of my cases had oxygen 
and none of them had strychnin or alcohol unless it was a person who 
had used alcohol constantly or daily and in these cases I consider that 
the system has become sufficiently used to it that it is practically a food 
and that sudden withdrawal is apt to bring on delirium. It is not neces- 
sary in those cases that indulge deeply now and then, but it is advisable 
in those that take a small amount regularly, just as they take food. These 
patients are used to a constant heart stimulant and its withdrawal is 
also apt to be reflected in the heart action. These are the only cases in 
which I have ever authorized anything in the way of a chemical stimu- 
lant of the heart during pneumonia. 

You will undoubtedly recall that in reading the newspaper accounts 
of men who are big enough and prominent enough to have bulletins in 
the newspapers when they are dying, that almost universally the next to 
the last bulletin was that oxygen is being administered. The last bul- 
letin announces the time of death. You will also note that in case the 
patient lives that oxygen then is not mentioned, and a few days later 
the patient is all right. My observation is that the use of oxygen may 
attract the attention of the family, it may attract the attention of the 
patient, but as for any actual benefit on the patient I do not beheve it 



320 The Practice of Osteopathy 

is in the least helpful, and that the only treatment for pneumonia is os- 
teopathic. I am so convinced of it that I am using only that method. 

As to strychnin, some say strychnin must be given. Some say it 
must be given at the crisis, and others say it must be given from the 
inception of the disease. I do not believe the majority of cases will 
do as well under strychnin. I know they will not do as well under strych- 
nin as under osteopathic treatment. I will not say they will not do as 
well as if under no treatment. It is possible that there would be an oc- 
casion for its use at the crisis, and I have seen such cases, and I have 
used it while studying medicine. I used it at the crisis, and I used it in 
cases where I am convinced that it helped them over the crisis, but I 
am also convinced now that by osteopathic treatment they would have 
done still better and the crisis would not have been so acute. In other 
words what strychnin does in favorable cases, osteopathic treatment 
does better in all cases. 

In our post-operative cases study the charts and you will see that 
they do not have the acutel}^ violent crisis that usually occurs under 
other treatment. They are under better control and if we can get them 
near the beginning, as we usually do, we can keep up the resistance so 
that where they would otherwise have a hard crisis they have an easy 
one. Instead of having a temperature of 105, pulse 165, respiration 70, 
or such a condition, they are more apt to run a temperature of 102, pulse 
120, respiration 35 or 40 and they go through it without that suddenness 
and acuteness that is common under other methods of treatment. 

In several instances, as an example of showing how this resistance 
is kept up, I had letters from boys in the camps. One letter told of a 
wide epidemic of severe tonsilHtis. In one group of soldiers there were 
three osteopaths who treated all the men and this was the only group 
that was not sent to quarantine. This group developed sore throat and 
was treated osteopathically and the sore throats checked so that quaran- 
tine was unnecessary. 

Among the detailed reports in the A. M. A. Journal there will be 
nothing about this, nor about many other instances where osteopathic 
treatment, given by men forced to remain in the ranks, has done things 
that medicine cannot do. These examples are too frequent to be co- 
incidents. If I had had three cases of post-operative pneumonia and 
they had all got well, it would not be surprising. If I had ten cases and 
they all got well, there are medical hospitals that have been this lucky. 
But there are no medical hospitals in the world that can report one hun- 
dred cases or two hundred cases or three hundred with developed pneu- 



The Practice of Osteopathy 321 

monia and all lived. The percentage of pneumonia eases that die now 
in medical hospitals, is much less than formerly. But the cause of this 
is not vaccine, antitoxin or drugs. It is due to the fact that pneumonia 
cases now, hke typhoid, are given very Httle medicine and are turned 
over to general nursing treatment; that is, in the best medical hospitals. 

The mortahty is in inverse ratio to the drugs given. The advance 
medical teaching is against so much drugs in pneumonia, though of 
course the hick doctors use it because they are practicing medicine of 
the by-gone age, before Andrew Taylor Still forced on the world the idea 
partly started by homeopathy, that the less drugs the better. Home- 
opathy failed in not quite discarding drugs and in not having a substi- 
tute that reproved drugs. 

As a matter of interest I wish to mention that while in medical col- 
lege I had the advantage of being taught surgery by the greatest sur- 
geon that ever lived, John B. Murphy. I only wish that circumstances 
could have permitted me to have shown him what osteopathy could do 
in post-operative conditions, because Murphy was a broad minded man 
and no man living ever thought less of orthodox medicine and old fash- 
ioned drug treatment than Murphy. 

He and the Old Doctor would have been great friends had they ever 
met. Murphy, whom I considered a most wonderful surgeon, and whose 
skill! never hope to approach, stated to me many times while a student 
that he lost more cases from post-operative pneumonia than any other 
condition and that in upper abdominal conditions like gall bladder, 
stomach, and similar operations, post-operative pneumonia constituted 
the most of his mortahty. 

This great man was afraid of post-operative pneumonia, while I, 
a much less skilled surgeon, am no more afraid of post-operative pneu- 
monia than I am of something occurring in a distant state because with 
osteopathic treatment, v/e have ehminated post-operative pneumonia 
as a fatal condition. 



PART SECOND 



The Practice of Osteopathy 325 

INFECTIOUS DISEASES 
Fever 

Fever is due to various causes, so that a definite statement cannot 
always be given as to the cause of fever in every disease. Each fever 
case, Hke all other disorders, is a law unto itself; different causes are 
found in different cases. Moreover, often only theories, and not abso- 
lute facts, can be given. 

Fever may be present when a local disease assumes a constitutional 
character or when the constitutional character is manifested from the 
beginning of the disease. Fever may be a systemic disorder or a symp- 
tom of disease, and is characterized by an increase of body temperature. 
Other symptoms are usually present, as an accelerated pulse, disturb- 
ances of distribution of the blood, increased catabolism, and disordered 
secretions. 

Etiology. — In infectious diseases fever is due chiefly to the action 
of various toxic or harmful agents, produced by the disease, upon the 
fluids of the body and upon the nervous system. Disturbances of the 
thermogenic centers and nerves of the brain or cord by harmful agents, 
or by lesions of the anatomical structures affecting these nerves, are 
sources of fever. Also disturbances of the vasomotor centers (in the 
medulla and auxiliary centers along the cord) and nerves are causes of 
fever in many instances. A disturbed or lessened function of the nerves 
controlling sweating is an important factor. The multiplication of mi- 
cro-organisms in the body, acting directly on the tissues or by producing 
toxic substances which affect the nervous system, is a fruitful source of 
fever. A few cases may be caused by direct affection of the nervous 
system, as is shown by appearance of fever in epileptic attacks, or by 
the passage of a catheter into the bladder. In a large number of all cases 
a demonstrable cause can be found upon careful examination, whether 
the fever be due to a necrosed mass of tissue, the introduction into the 
system of decomposed food, infectious diseases, a lesion of some ana- 
tomical structure affecting a thermogenic, vasomotor or sweat center, a 
lesion to the innervation to the heart (vagi and cervical sympathetic) 
causing a rapid heart, or a lesion to the lymphatic system. 

Treatment. — The treatment of fevers in a general way consists 
principally of thorough inhibition to the posterior spinal nerves of the 
upper cervical region in order that the center of the vasomotor system 
in the medulla may be affected, probably by the way of the superior ccr- 



326 The Practice of Osteopathy 

vical ganglion of the sympathetic. Thus the entire vascular system is 
equalized, for there is always a disturbance in the distribution of the 
blood in fever and if the center controUing the nerves that govern the 
lumen of the blood-vessels can be brought under control, there will result 
an equalization of the vascular system; if such occu^-s, health must ensue. 
Besides the vasomotor nerves to the blood-vessels being affected by this 
treatment, the nerves governing the lymphatics and the sweat glands 
will also be controlled. The sweat glands as a rule are rendered active 
by affecting directly the innervation of the glands, also the glands are 
controlled indirectly by the blood supply; this aids materially in lessening 
the temperature of the body. Treatment for a few minutes to the upper 
posterior cervical region would also affect the thermogenic centers and 
nerves of the brain reflexly in the same manner as the vasomotor and 
sweat centers and nerves are affected, thus tending to equalize the mech- 
anism of the thermogenic system. Besides this action on the vaso- 
motor, sweat, and the thermogenic nerves, there is produced an increased 
exhalation of moisture from the lungs, on account of an increase of vas- 
cular area in the lungs through vasomotor action. Also the large vas- 
cular area in the abdomen, under control of the splanchnic nerves, be- 
comes constricted. Thus there is brought about a lessening tempera- 
ture by evaporation, heat radiation, and perspiration; and an increased 
action of the general nervous system, a stronger cardiac force, an equali- 
zation of the vascular system, and a more perfect elimination of toxic 
properties by the skin, kidneys and lungs; consequently a reduction of 
the fever. 

The foregoing treatment is successful to a limited extent, onlj^ in 
such cases where causative factors of the fever are involving the pre- 
dominating centers controlling the heat production or dispersion and the 
vasomotor system directly; for if the lesion that is causing the disorder 
should be affecting an auxiliary center along the spinal cord instead of 
the predominating center, as is oftentimes the case, treatment of the 
predominating center would be useless as far as any permanent benefit 
is considered; although a temporary effect will be gained by lessening 
the fever at that point. Consequently, in many cases, the lesion hes 
within the jurisdiction of auxiliary centers which are situated at various 
points along the spinal cord. When such is the case, it will be of little 
benefit to give the cervical treatment. In such instances the lesion 
to the auxiliary center would have to be removed in order to cure. One 
cannot depend upon a set rule to reduce a fever; determine the cause, 
as in any other disease or symptom, and remove it. 



The Practice of Osteopathy 327 

In addition to the treatment to the cervical region and along the 
spinal column, as are indicated upon an examination, attention should 
be given to the heart's action. The equihbrium between the accelerator 
and inhibitory nerves (cervical sympathetic and vagi) should be main- 
tained. The interchange of gases in the lungs should be rendered as 
nearly normal as possible; this is best accompUshed by raising and spread- 
ing of the ribs from the second to the seventh dorsals, particularly in the 
region of the fifth and sixth. Also stimulation of the vagi will aid by in- 
creasing the motor power of the lungs. The kidneys and bowels should 
be kept active so as to favor a rapid elimination of various toxic proper- 
ties; besides they have control over large vascular areas. Treatment 
over the ureters will prevent any clogging that might occur in them 
from a condensation of the urine. Attention, also, should be given the 
tissues at the fifth lumbar and over the ihac vessels to influence the cir- 
culation in the pelvis. 

The food of the patient should be Hquid — milk, soup, broths, etc., 
and almost any quantity of water allowed if called for, given httle at a 
time and at frequent intervals. The room should be well hghted, venti- 
lated, clean and kept at an even temperature. 

Two points should always be remembered relative to fever: 

First — That there are many causes of fever; and in order to reduce 
the fever the cause must be determined and removed, the same as in 
any disorder. A definite fever treatment cannot be given any more 
than a definite constipation treatment; the case must be seen in order to 
determine the cause. 

Second — The reduction of fever is not necessary; the fever should 
be treated only as a symptom of disease when it exists as such. In fact, 
fever is beneficial, for it is one of nature's methods to relieve an over- 
burdened system from harmful agents, unless the temperature is ex- 
cessive and continuous and is Hkely to cause more harm than the pri- 
mary trouble. 

Absolute rest in bed always is of decided benefit in lessening the 
temperature. 

Hydrotherapy is of immense value in reducing a fever. It is an 
agent that has been greatly used, and if applied intelhgently cannot but 
be of aid. There is much ignorance in regard to the principles and prac- 
tice of hydrotherapy, not only among all classes of people, but among 
well informed practitioners in medicine. The most important func- 
tion of the skin is as a heat regulator. Knowing this fact, the osteopath 
treats the vasomotor nerves that control the cutaneous circulation and 



328 The Practice of Osteopathy 

the nerves that control the excretion of the skin; the nerve supply being 
from the cerebrospinal and sympathetic nerves. In many difficult and 
obstinate cases hydrotherapeutic measures should be used to aid the 
skin in regulating the temperature, as well as to enhance system func- 
tions for the same reason that osteopathic manipulations are given. 
Maintaining an equilibrium in heat production and heat dispersion is 
necessary in order that the standard of the body temperature may be 
kept; and the amount of the arterial blood circulating within a tissue 
determines its temperature. 

The principal effect of water as a thermic agent when applied ex- 
ternally is due to the influence of the action of the water upon the cu- 
taneous circulation. Lesser effects would be the mere extraction of 
heat from the body by evaporation and the equalization of tempera- 
tures of two bodies coming into contact. As the bod}^ is endowed with 
compensatory powers, tliis latter means would apply only to a Hmited 
extent. The temperature of the water used is important, as the colder 
the bath the less effective would its power be in reducing internal tem- 
perature. When a cold bath is used there is a driving of the blood away 
from the surface on account of the contraction of the peripheral vessels; 
consequently increasing the cutaneous circulation and cooUng by radia- 
tion is prevented and less heat is lost. A collateral hyperemia occurs 
in the underMng parts which acts as a protection to the deeper tissues. 
The cold also inhibits the vasomotor nerves controlling the abdominal 
splanchnics, and thus a larger amount of blood passes to tliis immense 
vascular area. On the other hand, when a warmer bath is used the 
effect is opposite, and a lowering of the temperature is the result. The 
cutaneous vessels being dilated, the superficial blood is rapidly replaced 
by blood from the deeper vessels, thus allowing a cooling of the body to a 
large degree. 

In the various fevers where hydrotherapeutic measures are em- 
ployed, the object to be gained by such methods is not primarily an anti- 
thermic one but an anti-febrile reaction; consequently the use of cold 
water is employed. In mere heat reduction the warmer water would 
be more effective; but by the aid of the colder water the cause of the 
increased temperature, as in infectious fevers, is lessened; besides a re- 
freshing and stimulating effect upon the entire system is gained. Thus 
the aim of the cold bath and friction, is not primarily to subdue the 
temperature by heat radiation or evaporation, but to correct disturb- 
ances governing the formation and the dissipation of heat caused bj^ 
infectious fevers, and, moreover, to stimulate the nervous sj'stem, pre- 



The Practice of Osteopathy 329 

vent heart failure, increase the eliminating power of thefskin, kidneys 
and lungs, and to influence the corpuscular and chemical constituents of 
the blood to a more normal condition. 

The full cold bath and friction (Brand Method) is commonly em- 
ployed in infectious fevers. The half bath, wet pack, or sponging may 
be used. The modus operandi of each is given under the hydrothera- 
peutic treatment of typhoid fever. 

Typhoid Fever 

(Enteric Fever) 

In writing of these acute diseases which are self-hmiting, it is under- 
stood that osteopathy aborts, overcomes symptoms and otherwise changes 
conditions frequently. When this occurs the case is not typical and it 
is a typical case which is here described. 

Deftnition.— An acute, infectious disease caused by the bacillus 
typhosus. It is characterized anatomically by hyperplasia and definite 
lesions of Peyer's patches and mesenteric glands, and enlargement of 
the spleen, and chnically by its slow onset, often diarrhea, abdominal 
tenderness, tympanites, fever, headache, and rose colored spots on the 
abdomen. 

Osteopathic Etiology and Pathology. — Lesions to the lower 
dorsal and lumbar regions are always found, which impair the innerva- 
tion and vascular supply of the intestines and cause defective nutrition. 
This is the most important predisposing cause, although general low- 
ered vitality from over-work, improper food, unhygienic environment, 
and insanitary surroundings, are also of great importance. It is possible 
that one's vitaHty may be so lowered that the bacillus of Eberth, if of 
sufficient numbers or virulency, wiU find a suitable medium wherein to 
multiply and grow, and thus the spinal lesions found in these cases are 
the result of reflex irritation. But the most probable underlying cause 
is the spinal lesion, and given two individuals with equal Hkelihood to 
infection, one with the spinal lesions and the other not, the former within 
all probabihty will be the more likely to suffer an attack. The severity 
and extent of the osteopathic lesion undoubtedly bears a direct ratio to 
the probability of attack from an infectious disease. Typhoid fever 
usually occurs between the ages of fifteen and thirty years. Some fam- 
ilies are more susceptible than others. The autumn months, especially 
after a dry, hot summer, favor the disease. One may be reasonably 
certain that whenever there is a case of typhoid the individual has not 
been careful as to diet, or drinking water, or some rule of health, and 



330 The Practice of Osteopathy 

wherever there is an epidemic it can always be traced to insanitary sur- 
roundings, the water supply, contaminated garden truck or other food, 
sewage, etc.; although tliis does not preclude the probability that the 
osteopathic lesion or lowered vitahty of Peyer's patches and mesenteric 
glands from other causes are important and many times primal etio- 
logical factors. The specific poison may be so virulent that practically 
no one escapes and again those of lowered vitality only will succumb to 
an attack. 

The exciting cause is a special micro-organism, the bacillus of 
Eberth. The contagion may be carried through the air from one person 
to another, but this is rarely the case. Though the water is the most 
common mode of conveyance, the bacillus has been found during epi- 
demics in both water and milk. The water may be contaminated by 
the intestinal discharges which have not been properly disinfected. Ex- 
treme cold does not destroy the typhoid germs. Millv may be infected 
from the milk-can being washed with the contaminated water or the 
unclean hands of the milker. In fresh millv the germs multiply rapidly. 
Salads, celery, ice and fruits may be contaminated. Oysters have be- 
comed infected while being fattened or freshened. It is thought by some 
that the poison is not eliminated from the sick in a condition capable of 
transferring disease to a healthy person, but must undergo changes in 
the soil before it is able to cause the disease in another. Typhoid fever 
may be caused, however, by direct contact with the stools. Filth, sew- 
ers, or cesspools do not directly cause the disease, but they form a suit- 
able medium for the preservation of the typhoid germs. 

Pathologically, the characteristic lesions in typhoid fever consist 
of changes in the lymphoid elements of the bowels. These changes are 
most striking in the solitary glands and Peyer's patches. The altera- 
tions which occur may be divided into four well defined stages: (1) 
Infiltration — the glands are enlarged from infiltration and there is 
marked cell proUferation, particularly Peyer's glands in the jejunum and 
ileum and to a lesser extent those in the large intestine. The glands be- 
come pale and prominent. Occasionally the soUtary glands, which are 
usually deeply imbedded in the submucosa, become prominent ho 

Microscopically, the capillary blood-vessels are at first consider- 
ably dilated, but later become more or less contracted, giving an anemic 
appearance to the folHcles. The adjacent mucosa and muscularis may 
become infiltrated. The cells have the character of lymph corpuscles, 
some of which are larger, epithelioid in character, containing several 
nuclei. From the eighth to the tenth day this medullary infiltration 
reaches its height and then undergoes either resolution or necrosis. 



The Practice of Osteopathy 331 

(1) Resolution takes place by a granular or fatty infiltration 
of the cells. This produces pitting of the swollen follicles, which may 
cause small hemorrhages. 

(2) Necrosis. — With all the severe cases of cell infiltration, hy- 
perplasia of lymph follicles reaches a stage where resolution is impossible 
and necrosis occurs. The necrosis is partly due to the choking of the 
blood-vessels and partly to the direct action of the bacilli. The necrosis 
may involve only the superficial layers of the mucosa or it may extend 
deep into the muscular coat and even perforate the outer or serous coat. 
Usually, however, this does not extend below the submucosa, mucosa, 
or muscularis. Not all of the patches necessarily slough, but as a rule 
it is always more intense toward the iliocecal valve. 

(3) Ulceration. — The extent and depth of the ulcers depend upon 
the amount of the necrosis.- Large ulcers are sometimes formed, es- 
pecially in the lower end of the bowel, by the union of several. The edges 
are swollen and undermined. The base is usually smooth and formed 
of submucosa. Perforation of the bowel occurs in a small percentage 
of cases; more commonly the ulcers heal. The perforations may be 
multiple, but rarely exceed two in number. 

(4j Healing.— Cicatrization begins about the fourth week. This 
granulation tissue covers the floor. It is sometimes formed with con- 
nective tissue and a new growth of epithehum results. The gland is ul- 
timately replaced by a depressed scar with a smooth, pigmented sur- 
face. The majority of deaths occur before this stage is reached. The 
gland structure is never regenerated. 

The mesenteric glands show intense hyperemia and later become 
enlarged and softened, but rarely ruptured. The glands at the lower 
end of the ileum are markedly involved. 

The spleen is enlarged, softened, and diffluent. Occasionally 
rupture occurs. Infarction is not a rare occurrence. 

The liver shows parenchymatous and granular degeneration, and 
the cells are found to contain much fat. Infarction abscesses and acute 
yellow atrophy occur in rare instances. Diphtheritic inflammation of 
the gall-bladder sometimes occurs and the bile is thinner and paler than 
normal. 

The kidneys also show parenchymatous degeneration. They are 
pale in appearance, with shght cloudy sweUing. Microscopicallj'-, there 
are seen granular and fatty infiltration of the cells of the convoluted 
tubules. Rarely, there is acute nephritis which may be hemorrhagic. 
There may be miliary abscesses in which typhoid bacilH have been found 



332 The Practice of Osteopathy 

by some observers. Diphtheritic, but more frequently catarrhal, in- 
flammation of the pelvis of the kidney may occur. Catarrh of the blad- 
der is not infrequent and even sometimes diphtheritic inflammation is 
present. Rarely orchitis is encountered. 

Hypostatic congestion of the lungs is not uncommon. Gangrene 
and hemorrhagic infarction are sometimes present. Lobar pneumonia 
may be a compUcation. 

In the larynx ulceration is sometimes met with; bacilli, however, 
have not yet been found in these ulcers. Diphtheritis of the pharynx 
and larjTix may occur. Catarrhal or croupous pharyngitis may oc- 
cur; while swelling of the follicles of the pharynx and base of the tongue 
is frequently noticed.- 

Peritonitis is always present in fatal cases in wliich perforation of 
the bowel has taken place. The perforation insiy occur in ulcers from 
which the sloughs have already separated, or it may be caused by a ne- 
crosis of all the coats. Extensive peritonitis may occur without perfora- 
tion, and is probably due to extension of the inflammation to the peri- 
toneum. 

The heart may be affected. Endocarditis is rare, while peri- 
carditis is much more frequent. Myocarditis is frequently met with, 
the cardiac muscles presenting parenchymatous and rarely hj^ahne de- 
generation. The arteries are frequently found to be involved. These 
conditions (obHterating arteritis and partial arteritis) may affect the 
smaller vessels, especiallj^ those of the heart, but more commonly affect 
the arteries of the lower extremities. Thrombosis of the veins, especially 
of the femoral, and more rarely of the cerebral veins and sinuses, occurs. 

Granular and hyaUne changes in the voluntary muscles may occur. 
This degeneration does not affect the whole muscle but involves only 
certain fibres. Regeneration takes place during convalescence. 

With the nervous system meningitis is rare. The peripheral nerves 
are frequently the seat of parenchymatous changes. The ganglia of 
the trunks of the vagi present an inflammatory change. 

The blood presents little change. During the first two weeks the 
red corpuscles gradually decrease in number until the first week of con- 
valescence, after which they gradually increase in number. There is 
often a marked decrease in the number of leucocytes. Leucocytosis is 
absent. The hemoglobin is always reduced. 

Symptoms and Course. — The incubation period varies from a 
few days to two weeks or longer. During this time the patient may 
feel in his usual health, but more often there is a feehng of languor and 



The Practice of Osteopathy 333 

indisposition to exertion, loss of appetite, slight coating of the tongue, 
nausea, headache, chilUness, but seldom a decided rigor, pains in the 
back or legs and nose-bleeding. Any of these symptoms may be present 
and last usually from a few days to a week or more. These symptoms 
increase in severity and the patient takes to his bed. The invasion as 
a rule is gradual. 

The first week dates from the onset of the fever which generally 
(but by no means in all cases) rises steadily during the first week a de- 
gree or a degree and one-half each day, reaching 103 or 104 degrees F. 
The pulse is quickened to 90 to 110 per minute and is full, of low tension 
and sometimes dicrotic. There is great thirst, also a coated tongue. 
The skin is hot and dry and there is rather intense headache. Unless the 
fever is high there is no dehrium. The sleep is disturbed and there may 
be mental confusion and wandering. Cough with some thoracic op- 
pression is not uncommon at the onset. The abdomen is slightly dis- 
tended and tender. There may be either constipation or diarrhea. The 
spleen is somewhat swollen and a rose colored rash appears on the skin 
of the abdomen and chest. 

During the second week the fever remains high and exhibits the 
continued type, the morning remission being sUght. The pulse is ac- 
celerated. The headache disappears, but there is marked mental dull- 
ness and slowness and there may be a mild delirium at night. The tongue 
is coated and the hps are dry. The abdomen is tympanitic and tender. 
Diarrhea replaces constipation. The case may prove fatal during this 
week from the result of nervous or pulmonary symptoms, hemorrhage, or 
perforation. 

The fever changes in the third week from a continuous to a re- 
mittent type. The pulse ranges from 110 to 130. The patient is very 
weak. CompMcations may arise, as pulmonary symptoms, feebleness 
of heart, intestinal hemorrhage, perforation, and peritonitis. 

In favorable cases during the fourth week the fever begins to 
dechne and the general and local symptoms gradually disappear. In 
protracted cases the fourth and fifth weeks may present the symptoms 
of the third week. Frequently the following aggravated symptoms 
are added: stupor, dehrium, increased weakness, rapid, feeble pulse, 
and distended abdomen. Heart failure and inflammatory complica- 
tions increase the danger. 

During the fifth and sixth weeks a few cases will show irregular 
lever. Great care should be taken that comphcations do not occur. 

The fever is the most important and characteristic symptom and 



334 The Practice of Osteopathy 

from the temperature alone a diagnosis may be made. During these 
stages of development, which is the first four or five days, the tempera- 
ture rises steadily; the evening temperature being about a degree or a 
degree and one-half higher than the morning remissions, reaching 104 
or 105 degrees F. at the end of the first week. When the fastigium is 
reached the fever persists with slight morning remissions.. At the end 
of the second and throughout the third week the temperature becomes 
more remittent and there may be a difference of three or four degrees 
between the morning and evening temperature. During the last stage the 
fever falls by lysis, forming a more or less regular step-like fine of descent. 
The stage lasts from one week to ten days. 

When the disease sets in with a severe rigor the fever frequently 
rises at once to 103 or 104 degrees F. In the hghtest forms the fastig- 
ium may be almost absent; defervescence setting in upon the first day 
of the fastigium and in many cases defervescence occurs at the end of 
the second week and the temperature may fall rapidly, becoming normal 
in ten or twenty hours. This fall in the temperature may take place 
without any apparent cause or it may follow an intestinal hemorrhage. 
The temperature often falls many hours before the blood appears in the 
evacuations. The occurrence of peritonitis is also marked by a sudden 
fall in the temperature. Hyperpyrexia in typhoid fever is not very 
common except just before death. 

After the temperature has been normal for several days there may 
be a sudden rise of the temperature to 102 or 103 degrees F. This may 
persist for a couple of days and then return rapidly to the normal. These 
recrudescences, as they are called, are quite common and are caused 
most frequently by errors in the diet, constipation, excitement or mental 
emotion. These elevations in the temperature are found most frequently 
in children and persons of a nervous temperament. 

Afebrile Typlioid is of very rare occurrence. The patient has 
all the characteristic symptoms of typhoid fever with the exception 
of a fever. 

The rasli is highly characteristic. It appears about the eighth 
or tenth day, usually upon the skin of the abdomen or chest, rarely found 
elsewhere on the body. It consists of a variable number of rose colored 
spots distinctly elevated, and disappear on pressure. These spots last 
three or four days and appear in successive crops. Vivid red erythemat- 
ous eruptions upon the chest and abdomen are commonly seen during 
the first week of typhoid fever. Urticaria is rarely seen. 



The Practice of Osteopathy 335 

Sweating characterizes some cases of typhoid fever, but generally 
the skin is dry. This may occur with or without chilly sensations or 
actual rigors. In some cases there may be recurring paroxysms of chills, 
fever, and sweats and they may be mistaken for intermittent fever. 
Edema of the skin may occur and is usually due to anemia or cachexia 
and sometimes to nephritis. Local edema may occur as the result of 
vascular obstruction, particularly thrombosis of the femoral vein. There 
is a pecuKar musty odor exhaled from the skin in typhoid fever, particu- 
larly if the skin has been neglected. In all protracted cases bed-sores 
are Ukely to develop. The hair is apt to fall out but is generally re- 
newed. The nails also suffer and ridges can usually be observed upon 
them. 

Intestinal symptoms are very inconstant. Usually there is 
constipation at the onset and this may persist throughout the disease 
although a moderate diarrhea may occur throughout the disease. The 
severity of the diarrhea is due most probably to the degree of the ca- 
tarrh rather than to the extent of the ulcers. It is probable that the 
discharges are more frequent when the catarrh involves the large in- 
testine. The number of discharges average, as a rule, from two to four 
or more daily. The stools are either fluid or of the consistency of jelly, 
of a grayish-yellow color, alkaline in reaction 'and are very offensive. 

Hemorrhage is a serious symptom, but by no means always fatal. 
This usually occurs in cases of considerable severity and it generally oc- 
curs at the time of the separation of the sloughs during the third week. 
When it occurs quite early in the disease it is generally the result of 
hypereiTiia. It may be so slight as not to be noticed by the eye or it may 
be from one to three pints. Intestinal hemorrhage, however shght, is 
always a grave sjanptom. There may be symptoms of collapse and 
fall of temperature, or it may occur without any symptoms. 

Meteorism is an almost constant symptom, and when excessive 
adds to the seriousness of the case and corresponds generallj^ with the 
extent of local lesions. Abdominal tenderness and gurghng upon pres- 
sure in the right iliac fossa may be present ; pain is generally absent, and 
when present is usually slight. 

Perforation almost invariably causes fatal diffuse peritonitis and is 
the most serious compHcation. It may occur at any time but is most 
common between the second and fourth weeks. It is usually indicated 
by sudden acute pains in the abdomen and symptoms of collapse. As a 
rule symptoms of peritonitis appear at once; distension of the abdomen, 
great tenderness, and rigid abdominal walls. Vomiting, pinched fca- 



336 The Practice of steopathy 

tures, and rapid, small pulse shows general collapse of the circulatory 
system. 

Bronchitis is almost invariably present as an initial symptom. It 
is indicated by the existence of sibilant rales. The cough is generally 
sHght. 

Hypostatic congestion of the lungs and edema, due to enfeeble- 
ment of the cardio-pulmonary circulation, in the latter part of the disease 
are not infrequent. 

The pulse as a rule is not very frequent and is generally not in pro- 
portion to the fever until late in the disease; 90 to 120 is the usual range. 
During the first week it is about 100, full, and frequently dicrotic; later 
it becomes more rapid, feeble and small. In severe cases during the ex- 
treme debility of the third week the pulse may reach 150 or more (the 
so-called running pulse). During convalescence the pulse occasionally 
becomes subnormal and bradycardia is met with more frequently than 
after any other acute fever. 

The blood presents definite changes, some of which are important. 
In cases where there is profuse sweating or copious diarrhea, the red 
corpuscles may be relatively increased; this is due to the loss of water. 
In most cases there is httle change until the end of the second week. 
During the third week there is generally a decrease in the number of cor- 
puscles and of the hemoglobin, which is always reduced. Leucocytosis 
is always absent. The white corpuscles are slightly diminished espec- 
ially toward the end of convalescence. 

During the first week there is generally persistent headache, some- 
times neuralgia. There are a few cases in which the effects of the ty- 
phoid bacilli or their poison is manifested in the nervous system from 
the very onset. There are violent headaches, retraction of the head, 
rigidity, photophobia, twitching of the muscles, rarely convulsions, all 
indicating meningitis as which it is occasionally diagnosed. It must be 
remembered however, that aU nervous symptoms may occur independ- 
ently of a lesion of the nervous system. 

Delirium may exist from the onset, but it usually is not present 
until the second or third week and only in the severer cases. As a rule 
it is most marked at night. It is generally of the low, muttering type, 
very seldom maniacal. When the patient picks at the bed clothes or 
grasps at imaginary objects there is indication of danger, as it is a serious 
symptom. Convulsions are rare. 

The urine is diminished in quantity, high specific gravity, and of 
dark hue Both urea and uric acid are increased and the chlorids are. 



The Peactice of Osteopathy 337 

diminished during the first stages. About the stage of decHne the urine 
becomes hght in color and greater in quantity than normal. The spe- 
cific gravity is lowered, urea and uric acid are diminished, and the chlor- 
ids are increased. Febrile albuminuria is verj^ common but of no special 
significance. Acute nephritis may develop as a complication. Pyuria 
is not an uncommon complication and post-typhoid pyehtis may also 
develop. 

Malarial fever may be associated with typhoid, especially in ma- 
larial districts. Persons with tuberculosis, epilepsy, chorea, and other 
forms of chronic nervous diseases are liable to typhoid fever. In epi- 
lepsy and chorea the movements and fits usually cease during the at- 
tack of typhoid fever. 

Varieties of Typhoid are numerous and are named with reference 
to the degree of severity which varies from extreme mildness to extreme 
severity. 

The mild or abortive form is of frequent occurrence. The onset 
is usually sudden. The symptoms are similar to those of a typical case 
but much milder and appear earher than in the usual type. This form 
runs its course in about two weeks. The fever usually reaches 104 de- 
grees F. 

In the severe or grave form there is high fever and the nervous 
symptoms show a profound intoxication of the system. The grave types 
are those associated with serious compHcations or those cases which set 
in with pneumonia, Bright's disease, or cerebrospinal symptoms. 

In the latent or ambulatory form (walking typhoid) the symp- 
toms are very slight, the patient being hardly sick enough to go to bed. 
The symptoms may be of this character throughout the attack, and the 
patient may be able to be up and about. In other cases the first symp- 
toms are very mild, but later they may develop symptoms of the sever- 
est type. 

The Afebrile form is rare. Hemorrhagic typhoid is a very fatal but 
rare form. In this type there are cutaneous and mucous hemorrhages. 

Diagnosis. — As a general rule typhoid fever is easily recognized. 
The Widal test should be made. At times the diagnosis may have to 
be delayed until the distinctive signs appear, especially in those cases 
which come on with severe headache, dehrium, twitching of the muscles, 
and retraction of the head. In these cases the diagnosis of cerebro- 
spinal meningitis is invariably made, until the appearance of the colored 
spots on the abdomen, which must decide the diagnosis; Cerebrospinal 
meningitis being a rare disease and typhoid fever with severe nervous 



338 The Practice of Osteopathy 

symptoms quite frequent, it is more probable that it is typhoid. At 
least one-half of the cases termed brain fever belong to this class of ner- 
vous typhoid. 

Prognosis. — A positive prognosis can not be made, as even the 
mildest cases are Uable to have severe compHcations develop at any 
stage of the disease. Under osteopathic treatment the prognosis is 
undoubtedly more favorable than with the treatment of the older schools. 
If the osteopath can see the case early, the first week, there is always a 
chance to abort the attack. In all cases there is the probability that 
the attack will be shortened; this is a common experience. Price of 
Mississippi, has treated many cases, and invariabty when the patient 
is seen early the attack has been shortened to thirteen or fourteen days, 
whereas under other treatment the disease runs the usual course. Adsit 
of Kentucky, White of New York, and the staff of the American School 
of Osteopathy (Kirksville), as well as many others, have had the same 
experience. And if the attack cannot be aborted or shortened there is 
the further probabiUty that the severity will be lessened and complica- 
tions prevented. The prognosis is always more favorable in winter than 
in summer, and especially favorable in children. More women die 
than men, and fat persons stand the disease badly. 

Treatment. — Typhoid fever is one of the diseases that practi- 
tioners of all the schools are agreed that drug therapeutics avail but 
little in its treatment. The treatment of the older schools consists of 
prophylaxis, good nursing, attention to hygienic principles, dieting, 
and hydrotherapy. All of these have their places and are recognized 
by the osteopathic school. But the above methods are of the defensive 
only — allowing the disease to run its usual course and reducing the like- 
lihood of compHcations. On the other hand the above treatment coupled 
with osteopathy, not onty attacks the ravages of the disease defensively, 
but of more importance, the disorder is attacked offensively. Herein is 
where attacks are aborted, or shortened, or severity lessened, or com- 
plications prevented. The efficacy of osteopathy is due to the abilitj^ 
of the osteopath to treat disease, not only prophylactically and palli- 
atively, but of more consequence, aggressively. 

The correction of the spinal lesions in typhoid fever is of first im- 
portance. This treatment effects a tendency toward equahzed circula- 
tion of the intestines. The vasomotor nerves are disturbed by the above 
lesions which in turn produces stasis in Peyer's patches and the mesen- 
teric glands. Reversely some of the spinal lesions may be due to reflex 
stimuli, for "Kirk , . . states that muscular contractions produced 



The Practice of Osteopathy 339 

by reflex activity are often more sustained than those produced by di- 
rect stimulation of the motor nerves themselves."^ 

Prophylactic treatment is very essential, for typhoid fever as a 
rule is a preventable affection. Modern hygienic and sanitary resources 
enable a community to reduce the number of cases to a minimum. The 
number of cases in a locality depends almost directly upon the condi- 
tion of the water supply and drainage. Care should always be taken 
in regard to the source of drinking water and milk. During an epidemic 
the water should be boiled for half an hour before being used. The pa- 
tient should be isolated. In hospitals they should have special wards; 
in families a special apartment should be given them. Hygienic prin- 
ciples should be followed as in other infectious diseases. 

The methods of disinfection must be rigid to prevent the spread of 
an infection. The excreta (stools, urine, vomitus, and sputum) are to 
be received into a bed-pan or any appropriate receptacle containing 
half a pint of carbolic acid (one to twenty). Three or four pints of the 
carbohc acid (one to twenty) should then be added to the bed-pan and 
the contents mixed carefully before emptying. All utensils used in 
handHng the excreta are to be carefully disinfected by the same material, 
and dried. After every stool the nates of the patient should be cleansed 
by a cloth compress, wet with a solution of carboHc acid (one to forty) 
and the cloth burned. The sick room should be thoroughly ventilated 
each day. All utensils used about the patient in feeding should be boiled 
in water immediately after using. The bed and body Hnen is to be 
changed as soon as soiled and these, with all changed bath towels, blank- 
ets and rubber sheets, should be received in a sheet rinsed in carbohc 
acid (one to forty) and placed where they may be soaked in the solution 
for four or five hours. The clothes are to be boiled for half an hour. The 
rubber blanket is to be washed in the solution, dried and aired. 

The General Management, careful nursing and a regulated diet, 
is of paramount importance in the treatment of typhoid fever. The pa- 
tient should be placed in bed as soon as the disease is determined and 
there remain until the end of the attack. The room should be well 
ventilated and have a sunny exposure if possible. The single woven 
wire bed with soft hair mattress and two folds of blankets is best. A rub- 
ber cloth should be placed smoothly under the sheet. When a good 
nurse cannot be had, the attending osteopath should write out directions 
regarding diet, bed hnen, and utensils, and the disinfection of the ex- 
creta. 

1. Ilinckle— The Scientific Basis of Osteopathy. 



340 The Practice of Osteopathy 

A liquid diet should be administered. Milk is most commonly 
used; care being taken that it is thoroghly digested. If milk is not borne 
well by the patient, other foods, as whey, sour milk, buttermilk, and 
broths may be substituted. Give food that is easily digested and which 
leaves but httle residue. When milk is used alone, three pints at least 
may be given to an adult in the course of twenty-four hours; and it should 
always be diluted, preferably with plain water. Beef juice, mutton or 
chicken broth may also be used when milk is not agreeable. Albumin 
water, prepared by straining the white of eggs through a cloth and adding 
an equal amount of water, is an excellent food. Well strained, thin 
barley gruel is considered by many an excellent food for typhoid fever 
patients. Cases not able to take nourishment into the stomach, on 
account of vomiting and other causes, should be fed rectally to support 
life. Do not force feeding to an unwarranted degree. 

Recently a number of new diets have received commendation. 
These include the "high calory" diet, which includes three pints of milk 
with one of cream, two to eight ounces of milk sugar, eggs, butter; some- 
times cereals, toast, potato, and other soft foods are given. A full sugar 
diet, as of candy alone, is based upon the immediate absorption of sugar, 
its value as a source of energy, and the fact that a plentiful carbohydrate 
supply lessens the danger of acidosis.^ 

The best drink for fever patients is pure, cold water and they should 
be encouraged to drink freely of it. Barley water, ice tea, lemonade, or 
even moderate quantities of coffee or cocoa, may be given. 

By Osteopathic Treatment many cases of typhoid fever may 
be aborted, if treated correctly, during the first week. If the stage of 
necrosis of Beyer's patches has set in, one can either lessen the severit}" 
of the attack or, at least, shorten the usual course. During the stage of 
infiltration, treatment to the intestinal splanchnics (chiefly from the 
ninth to twelfth dorsal, the innervation to the jejunum and ileum) and 
careful treatment over the abdomen is indicated. This treatment will 
tend to lessen the intestinal catarrh and diminish the infiltration and 
cell proliferation of the lymphoid elements of the inteatines, and thus 
produce unfavorable the conditions for the bacillus of Eberth. In 
other words, increase the tone and activity of the intestines so that the 
micro-organisms of typhoid fever will not find the proper tissue-soil in 
order to grow and multiply. 

All cases of tj'^phoid fever present lesions in the dorsal or lumbar 
spine and this is really the great predisposing cause of typhoid fever. 
2. Clinical Osteopathy. 



The Pkactice of Osteopathy 341 

Correcting these lesions is absolutely necessary in order to abort the 
disease. Some patients may have such a lowered vitahty to begin with 
that the recuperative powers of the body cannot be rendered forceful 
enough in a short time to combat the effects of the micro-organism. 
Carefully raising the cecum is very effective (A. T. Still), but this must 
be done with the greatest of caution and judgment. Dr. Still considers 
a posterior condition of the third, fourth and fifth lumbars as typical in 
typhoid and that it inhibits the lymphatics to the intestines. 

R. L. Price has had excellent success in shortening the usual typhoid 
course. His first treatment is to thoroughly empty the bowels by ene- 
mata. This is followed by spinal, liver and splenic treatment, and i 
liquid diet. 

E. C. White has also treated a large number of typhoid cases with 
marked success. He prefers to employ the Brand method (and it must 
be properly used) from the start. He is, also, a thorough advocate of 
the spinal treatment. In cases of constipation give a very light treat- 
ment over the left iliac fossa. With all patients observe careful dieting. 
White believes that many lesions of the spine arise from reflex irritations 
during acute attacks. Careful, frequent attention to the spine is de- 
manded. 

Hildreth, relative to abdominal and spinal treatment, writes as fol- 
lows: "In the abdominal treatment of typhoid fever, too much care 
cannot be exercised; or in the spinal treatment, too much judgment used 
in giving just the right kind of manipulation. There can be no ques- 
tion relative to the seat of the disease, and consequently there should be 
no trouble in knowing where or how to affect the nerves to control the 
same. That Peyer's patches or the right iliac region is always involved, 
we all know. The spinal treatment should be appHed from the eighth 
dorsal to the first lumbar inclusive; this affects all the lesser splanchnics 
and thus controls the circulation of the entire bowel. And this treatment 
should be given, according to the symptoms indicated, in each and everj^ 
case. If the patient is constipated, then the treatment should be more 
of a stimulative character, but if diarrhea is present, as is commonly the 
case, the treatment should be an inhibitory one. In the above I always 
finish with a very careful treatment of the floating ribs on the left side; 
this affects the lesser splanchnic nerves. In all cases I always carefully 
treat the lower two or three lumbar vertebrae, which directly affects the 
hypogastric plexus of nerves, and thus controls the circulation to the 
lower bowel. 

"In all cases I always treat the bowels directly, more or less, but 



342 The Practice of Osteopathy 

this treatment must be given with the veiy greatest care and the best 
judgment, always governed by the condition of the bowel. By no means 
manipulate the bowel, but just lay your hands flat on the abdomen, 
and with the most gentle pressure inhibit the peripheral nerves, thus 
either quieting an excited peristalsis or equahzing a disturbed circula- 
tion. And with this treatment remember that the two specific points 
in typhoid fever are the lower dorsal and lower lumbar nerves. 

"The above treatment is used, of course, in connection with all the 
other necessary treatments, such as dieting, nursing, sponging, reheving 
the headaches, etc. I am unalterably opposed to ice-packs for the bowels 
in typhoid, for the reason it is too much of a shock. Cold cloths are good 
and much better than ice, and should always be used instead of ice." 

After the disease has become thoroughly established always make 
it a point during each visit to examine the entire length of the spinal 
column carefully and readjust any tissue, whether it be vertebra, rib, or 
muscle, that may be found disordered. The bowels are to be watched 
carefull}^ and if constipated, they should be moved with a hght enema. 
Great care must be taken not to treat the abdomen roughly, if at all, 
after the first week. The treatment might be very injurious to the 
structures diseased. A Ught treatment over the liver and kidneys each 
time is a wise precaution. The heart's action, should be watched care- 
fully. In addition to the hydrotherapeutic treatment, the general fever 
treatment should be employed. The patient should usually be seen 
twice a day. 

Abdominal pain is best reheved by Ught treatment over the ab- 
domen and by thorough treatment of the lower dorsal or lumbar region. 
Apphcations of hot water will be helpful. 

Meteorism can be reheved by raising the lower ribs and by direct 
treatment to the abdomen. A change of diet may be beneficial. When 
gas is in the large bowel an enema may be given to remove it. 

Diarrhea and constipation are best controlled by the usual treat- 
ment given the spine in such cases, and over the abdomen and the hver. 
Light enemata may be given for constipation. The stools should be ex- 
amined when diarrhea occurs, as the presence of curds may cause the 
aggravation. 

Hemorrliage from the bowels demands absolute rest. It is prob- 
ably better to have the patient use the draw sheet for the evacuation. 
Immediate and thorough treatment must be given to the spinal column 
in the region of the intestinal nerves to the diseased area, so that existing 
lesions may be corrected and the vascular area of the mesenterj^ equal- 



The Practice op Osteopathy 343 

ized. Ice should be given freely and an ice-pack placed over the abdo- 
men. Food should be restricted for ten or twelve hours. If the peris- 
talsis of the intestines is increased, an effort should be made to control 
it through the vagi and splanchnic nerves. 

In perforation hot applications, rest and thorough treatment of 
the innervation to the peritoneum are of value, but immediate operation 
is usually advisable. 

Insomnia is best reheved by attention to the cervical region. Re- 
laxation of the muscles in this region and a quieting treatment to the 
posterior occipital nerves, coupled with cold sponge baths, will usually 
induce sleep. 

In delirium attention to the circulation of the brain, by careful 
treatment of the vasomotor system, and the Brand method of baths will 
reheve this distressing symptom. 

During convalescence the patient should be restricted from any 
mental or physical exercise for a week or ten days and then should move 
about with care. Sohd food should not be given for ten days or two 
weeks. If the temperature has been normal for ten days, it is then safe 
to allow such food as eggs, milk puddings, and milk toast. If diarrhea 
should persist, being due to ulceration, the diet should be restricted and 
the patient confined to the bed. If constipation is troublesome relieve 
it by enemata. 

There are several beneficial effects obtained by hydrotherapeutic 
measures that should receive careful consideration. Probably it is 
of the least significance to lower the temperature ; other beneficial effects 
being of greater importance. When the baths are systematically car- 
ried out, (1) there is obtained a general improvement of the nervous 
system, the mind is rendered clear, muscular twitchings are lessened, 
sleep is induced and the heart's action strengthened; (2) the respiration 
is stimulated, thus diminishing the liabiUty of lung compncations;(3) 
the activity of the renal function is increased, consequently allowing 
more rapid elimination of toxic matter; (4) reduction of the temperature, 
and overcoming ill effects of high fever. 

A cold water bath, or what is generally termed the Brand method, 
is commonly employed. The following plan is usually followed. When 
the temperature is above 102.5 degrees F., rectally, a bath of 70 degrees 
F. is wheeled to the patient's bedside and he is placed into it for ten or 
fifteen minutes. The patient should be lowered into the bath by means 
of a sheet. Enough water is used to cover the bodj^ and neck of the 
patient. The head is sponged and the limbs and trunk are rubbed thor- 



344 The Practice of Osteopathy 

oughly dining the entire procedure. When the patient is taken out he 
is wrapped in a dry sheet and covered with a blanket. This procedure 
is gone through with every three hours if the case is severe, otherwise 
once every seven or eight hours will be sufficient. 

The luke-warm bath is occasionally used in private practice when 
one is unable to use the Brand method. A bath of 90 degrees F. is em- 
ployed, which is gradually cooled ten or twelve degrees, after the patient 
has been placed in it, by pouring cold water on the patient. This bath 
is found very helpful. Also in private practice the cold pack is found 
satisfactory. The patient is wrapped in a sheet wrung out of water 
at 65 degrees F. and cold water is sprinkled over him. Whenever there 
is objection to any of these methods the body may be sponged off with 
tepid or cold water when the temperature rises above 102.5 degrees F., 
rectally. One Hmb should be taken at a time and then the trunk, occu- 
pjdng altogether some twenty or thirty minutes. 

The Great War brought the subject of typhoid vaccination before 
the world with emphasis but its results are not, as yet, in shape so an 
unbiased opinion can be formed. The army medical department will 
tell us that it was an unquahfied success but we do know that there were 
serious outbreaks among inoculated troops who were hving under most 
hygienic surroundings in America. There were, also, outbreaks among 
protected troops in France to the extent that the medical authorities felt 
called upon to warn all medical officers that vaccination should not be 
considered as protecting against unsanitary surroundings and that great 
precaution must be observed, the same as under non-vaccination condi- 
tions. This does not imply imphcit confidence. 

It is, also, a historical fact that the Japanese arm}', during the Russo- 
Japanese war had as low a rate of typhoid without vaccination as can, 
probably, be shown with it in this war. At that time they depended en- 
tirely upon pure water and sanitation. 

See reports of typhoid fever in A. O. A. Case Eeports as follows: 
C. M. T. Hulett, Series I, p. 7, J. H. Wilson, Series III, p. 3, F. E. and 
H. P. Moore, and F. A. and E. S. Cave, Series IV, pp. 4 and 5. 

In paratyphoid fever, an acute infectious disease caused by the 
paratyphoid bacilhis, the treatment is the same as for typhoid fever. It 
is milder and similar to typhoid fever. 

Typhus Fever 

Definition. — An acute, infectious disease; characterized by sud- 
den invasion, high fever, marked nervous symptoms, a pecuhar macu- 



The Practice of Osteopathy 345 

lated and petechial eruption and a termination by crisis about the four- 
teenth day. 

Etiology and Pathology. — Typhus fever is becoming less fre- 
quent than formerly and is rarely seen in this country. It was very 
destructive during the Great War, particularly in the Balkan states. 
Filth, over-crowding, famine, intemperance and bad food are the pre- 
disposing causes. Typhus fever is highly contagious and is transmitted 
by the pediculus corporis (cootie) as was first discovered by the American 
Red Cross workers in Serbia. Probably infection may come by contact 
and fomites. The specific organism is the bacillus typhi exanthematici 
(Platz). 

Pathologically, there are no constant lesions. There is a general 
hyperplasia of the lymph follicles, but no ulceration. The blood is dark, 
thin and lessened in fibrin. Hypostatic congestion of the lungs and 
bronchial catarrh are frequently met with. The hver, kidneys and spleen 
are found to be somewhat enlarged and softened. The petechial rash 
remains after death. 

Symptoms. — The incubation period is about twelve days. The 
onset is usually sudden, ushered in by chills. The temperature quickly 
rises to 104 or 105 degrees F. There is headache, pains in the muscles, 
especially of the back, and early, profound prostration. The pulse is 
at first full and strong, 100 to 140, but soon becomes weak and frequent. 
There may be distressing vomiting. The face is flushed, the eyes in- 
jected, the expression stupid, and there is generally low, muttering de- 
lirium. The tongue is furred and white, soon becoming dry. The bow- 
els are constipated and the urine is usually scanty and of high specific 
gravity. There is great thirst. Conjunctiva injected; pupils con- 
tracted ; early prostration. 

The eruption appears about the fifth or seventh day. It first 
makes its appearance upon the abdomen and chest. It rapidly extends 
all over the body with the exception of the face. The eruption is of two 
kinds — rose spots, which disappear upon pressure, and those which be- 
come hemorrhagic (petechial) ; pressure has no effect upon them. Dur- 
ing the second week the symptoms are increased. The tongue is dry, 
brown and fissured, and sordes appear on the teeth. Retention of the 
urine, due to paralysis of the bladder, is common. The breathing becomes 
more rapid and the heart's action more feeble; the patient may die from 
exhaustion. This ushers in the typhoid state with low, muttering de- 
lirium, ataxic symptoms, subsultus, tremors, and maybe bronchial 
symptms. In favorable cases the crisis occurs at the end of the second 
week. Patient sinks into a sound sleep, the temperature falls rapidly, 



346 The Practice of Osteopathy 

there is profuse sweating and a critical diarrhea but the patient now gains 
rapidly. 

Convalescence is usually rapid; relapses rarely occur. The urine 
is scanty, high colored and frequently albuminous. Bed sores are com- 
mon. The temperature continues high, reaching 106 degrees F., or more, 
with slight nocturnal remissions. In fatal cases the fever often rises to 
108 or 109 degrees F. just before death. 

Diagnosis. — The sudden onset, frequent chills, early profound 
prostration, character of the rash, historj'- of exposure to the poison and 
unhygienic surroundings decide the diagnosis. During an epidemic 
there is usually no doubt, but in sporadic cases the diagnosis is some- 
times extremely difficult. 

Prognosis. — This is usually grave, but the mortaUty rate is being 
greatly reduced in consequence of the better sanitary arrangements. 

Treatment. — Typhus fever is highly contagious and great care 
should be taken in controlling the disease. Isolation, disinfection and 
extermination is imperative. So far as known none of the osteopaths 
have had experience in the treating of typhus fever osteopathically, 
but there is no reason why the disease should not be treated with the 
same success as is met with by osteopathic treatment in other diseases. 
It is claimed that the disease should be treated in the open air, in tents, 
as the recovery of the patient and the safety of the attendants are greatly 
favored. 

For high temperature, besides the treatment given to remove any 
disorder that may be found, the general fever treatment is indicated, and 
hydrotherapy would also be of aid — sponging the surface of the body, or 
the use of the bath. Asthenia is wherein the greatest danger Hes, and 
a stimulating treatment along the spine and to the heart should be given ; 
although correction of the primary trouble may be sufl&cient. Hj'dro- 
therapeutic measures, the systematic use of the cold bath, would be of 
service the same as in typhoid fever. 

Headache and dehrium which are apt to arise, caused by too much 
blood in the head, may be relieved by treatment of the cervical spine. 
Also cold applied to the head will aid. Th'e bowels should be watched 
carefully; treat the splanchnics thoroughly and the intestines and hver 
directly. Nourish the patient as in typhoid fever by nutritious hquids — 
milk, broths, etc. 

Although typhus is now a comparatively rare disease, an outHne 
has been given to emphasize what correction of unhygienic conditions 
and insanitary surroundings will accomphsh. It is particularly a dis- 
ease of filth. 



The Practice of Osteopathy 347 

Malarial Fever 

(Ague) 

Definition. — An infectious disease caused by the hemocytozoon of 
Laveran. "It is characterized by paroxysms of intermittent fever of 
the quotidian, tertian or quartan type, a continued fever with marked re- 
missions, a pernicious or rapidly fatal form, and a chronic cachexia with 
anemia and enlarged spleen." (Halbert). The varieties of malarial 
fever are: intermittent fever; pernicious intermittent; remittent fever; 
malarial cachexia; masked intermittent; malarial hematuria. 

Osteopathic Etiology and Pathology. — Malarial fevers are caused 
by a parasite known as the hematozoon of Laveran. Three varieties of 
the parasite have been separated, corresponding with the three leading 
forms of the affection. The parasite of tertian fever is about as large 
as a normal red blood corpuscle, beginning as a small hyahne ameba in 
the red blood corpuscles. The parasite of quartan fever is very similar 
in its appearance to the tertian parasite but smaller; its ameboid move- 
ments are slower and the red blood-corpuscle embracing it shrinks about 
the parasite, assuming a deeper greenish color. The parasite of the es- 
tivo-autumnal fevers is still smaller. "If only one group of parasites 
exists the paroxysms— quartan intermittent — will occur every fourth 
day. Double quartan infection will result in paroxysms on two suc- 
cessive days with an intermission of one day. Infection by three groups 
of parasites will create daily paroxysms — the quotidian intermittent. 
Infection by more than three groups is rare." (Anders). Only in the 
earlier stages of development, small hyahne bodies are to be found in 
the peripheral circulation; being, in the later stages, in the blood of cer- 
tain internal viscera, spleen, and bone marrow, particularly. 

It is an accepted fact among medical observers that to the mos- 
quito, anopheles, is due the spread of malaria and it has been the sub- 
ject of much investigation in all parts of the world. The mosquito be- 
comes infected from biting an individual whose blood contains the malar- 
ial parasite, this is then developed in the mosquito to maturity and later 
is transmitted to the next subject bitten. This explanation would show 
why certain locahties favorable for the breeding of mosquitoes are par- 
ticularly given to malarial outbreaks. Low, marshy grounds, banks of 
rivers, small ponds, etc., as well as warm weather, are needed to produce 
the conditions for the development of the anop heles As the country 
has developed the intensity and extent of malaria has diminished until 
it is now confined largely to the southern states. It is practically un- 



348 The Practice of Osteopathy 

known in the northwest and in the St. Lawrence basin. Regions which 
have never had cases, however, have developed them when the anox)heles 
has appeared. Whiting notes cases in Southern Cahfornia, the result 
of the insect being brought in by ships from Mexican or Central Amer- 
ican ports. In certain regions the anopheles is present but has not ap- 
parently come in contact with a malarial victim, so is incapable of spread- 
ing the disease. Also in colder climates this species is harmless. 

By draining the lands and preventing the breeding places, the num- 
ber of the pests is reduced, while the screening of houses and care against 
exposure to the bites make it possible to Hve in malarial sections and 
not become infected. Naturally the resisting power of a patient is called 
into account when bitten by the mosquito. Where it is epidemic the 
inhabitants will be found, generally, poorly nourished or debilitated from 
climatic or other conditions. This renders infection easy, for immunity 
must come from the ability of the blood to combat the invading 
parasite. 

The osteopathic predisposing causes for malaria are usually 
interference with the vasomotor nerves to the spleen and liver, as these 
two organs are so concerned in maintaining the stability of the blood 
tissue. Ligon, of Alabama, notes that most cases have lesions between 
the ninth and twelfth dorsal on the right side. 

The chief morbid changes are due to the direct effect of the ma- 
larial parasite upon the blood. There are also changes in the liver, kid- 
neys, and spleen, which changes usually vary with the duration and in- 
tensity of the disease. The disintegration of the red blood-corpuscles, 
accumulation of the pigment thus formed, and the toxin engendered by 
the malarial parasite are responsible for the morbid lesions of the dis- 
ease. 

In pernicious malaria the blood is more or less hydremic, and the 
discs are seen in all stages of destruction. The spleen is enlarged and soft 
and the pulp dark from the accumulation of the pigment, and spontan- 
eous rupture has occurred in a numl^er of cases. The Hver is swollen 
and turbid; pigmentation occurs, but is generally only visible by means 
of the microscope. By the aid of the microscope all the tissues of the 
body, even the brain, may be found to be pigmented. 

The spleen in chronic malaria is greatly enlarged, firm, pigmented 
and the capsule thickened. The liver is enlarged, the color varying 
from a slight gray to a deep slate gray, according to the amount of pig- 
ment. The kidneys may be enlarged and deeply pigmented, as is also 
the mucous membrane of the stomach and intestines. 



The Practice of Osteopathy 349 

R, W. Connor observes that the kidneys and liver are most notice- 
ably involved, vasomotor obstructions the rule, the spleen in the majority 
of cases shows engorgement and that special attention to these centers 
will give the best results. He invariably finds spinal lesions from the 
seventh dorsal to the first and second lumbar, most frequently the eighth, 
ninth and tenth dorsals. A lowered vitality predisposes to infection 
from the bite of the mosquito. 

Symptoms. — Intermittent Fever. — This form is what is known as 
fever and ague, in which chills, fever and sweat follow each other. The 
period of incubation varies from six to fifteen days, but it may be months 
after exposure before the first paroxysms set in. The paroxysm is usually 
preceded by a feeling of uneasiness and discomfort, sometimes by nausea 
or headache. The paroxysm consists of three stages, cold, heat and 
sweating. 

In the cold stage the chill usually begins gradually; it is generally 
intense, the teeth chatter and the body shakes violently. The skin is 
cool and pale, the lips are blue, the face is pinched and the patient looks 
very cold. During the chill the temperature rises rapidly. Nausea, 
vomiting and headache are common. The pulse is frequent, small and 
hard. The urine is increased in quantity and of low specific gravity. 
The chill lasts from a few minutes to a couple of hours. 

The hot stage succeeds the chill. The skin gradually loses its 
coldness and becomes hot. The face is flushed, there is great thirst, the 
mouth is dry, and the tongue is coated. Usually at the termination of 
the chill the temperature has reached its maximum level, from 104 to 
106 degrees F. The pulse is full, and there may be a throbbing headache. 
The duration of this stage is from half an hour to three or four hours. 
During the sweating stage drops of perspiration appear upon the face; 
the perspiration soon becomes profuse, extending all over the body. 
The temperature soon falls, the headache disappears and in a couple of 
hours the paroxysm is over. 

The entire duration of the paroxysm is from eight to twelve hours; 
the patient usually feehng perfectly well between the paroxysms. The 
spleen is enlarged. If the paroxysms of fever occur daily at the same 
hour they are called quotidian intermittent fever; if every other day 
they are known as tertian intermittent; and if every third day they 
are called quartan intermittent. If there are two parosyxms in the 
same day the term double quotidian is used; if the paroxysms occur 
a couple of hours later each successive day they are called "retarding;" 
if a couple of hours earlier they are named "anticipating." 



350 The Practice of Osteopathy 

Remittent Fever. — (Estivo-Autumnal Fever). — This is charac- 
terized by a continued fever with parox3^smal exacerbations and re- 
missions. It occurs especially in warm and tropical climates. In tem- 
perate climates it usually occurs in the late summer and fall. It is also 
termed bilious remittent fever on account of the intensity of the gastro- 
intestinal manifestation. The estivo-autumnal parasite is the exciting 
cause. 

It is very often preceded by malaise, headache, nausea and vomit- 
ing. The onset is usually gradual and the chill may be wholly absent. 
As a rule, however, a chill generally occurs at the onset, but it is less 
severe than that of intermittent fever. After the chill the temperature 
rises rapidly to 102 or 104 degrees F. or even higher. The pulse is full, 
rising to 100 or 120. There is violent headache, flushed face, pains in 
the Umbs and loins, nausea and vomiting, and dehrium when the temper- 
ature is very high. The urine is scanty or even suppressed, slightly 
albuminous, sometimes bloody, high colored, and deposits a sediment 
of urates. Jaundice is not infrequent; the spleen is enlarged and herpes 
labialis is quite common. After six to twenty-four hours the symptoms 
abate and slight sweating occurs. The temperature usually drops to 
100 degrees F., the headache disappears and vomiting ceases; this is fol- 
lowed bj^ a new exacerbation of fever at the end of about twelve hours, 
generally without the chill; and this hot stage is in turn again followed bj^ 
the remission. These attacks may last three or four weeks. 

Pernicious Malarial Fever.— This is rare in temperate cUmates 
and is always associated with the estivo-autumnal parasite. The prin- 
cipal types are the cerebral and algid. 

The cerebral type usually begins with a severe chill; sometimes, 
however, the chill is absent. The patient is violently seized with grave 
cerebral symptoms, as acute delirium or sudden coma. The coma- 
tose condition lasts from twelve to twenty-four hours when consciou- 
ness usually returns, the primary paroxysm rarely proving fatal; it is, 
however, often followed in a short time by fatal relapse. 

The Algid variety is characterized by intense prostration and ex- 
treme coolness of the surface with the internal temperature high. The 
gastric symptoms are extreme nausea and vomiting. The pulse is feeble ; 
the breathing frequent and shallow. There is intense thirst. The voice 
is feeble and indistinct. The mind is clear. The urine is suppressed. 
In this type the parasites gain entrance to the gastro-intestinal mucosa, 
sometimes forming distinct thromboses of the smaller vessels. This form 
may be confused with yellow fever. 



The Practice of Osteopathy 351 

Malarial Cachexia. — This is a chronic condition which often occurs 
in cases that have not been properly treated or in persons that hve in 
malarial districts and are constantly exposed to the infection. The 
two most striking symptoms of this condition are anemia and an enlarged 
spleen or "ague cake." There is fever at intervals, but chills rarely 
occur. The skin is of a dirty yellow color. The spleen is greatly 
enlarged and the blood is profoundly anemic. There is debihty, and 
frequent sweating, and the hands and feet are cold. The digestion may 
be deranged and there may be sUght jaundice. Sometimes there is edema 
of the feet and even dropsy occurs. Hemorrhages of the various mucous 
surfaces are common. Paraplegia and orchitis are rare symptoms. 
These cases usually do well under proper treatment, and if the patient 
can be moved from the malarial district. 

Masked Intermittent. — Malarial neuralgia most frequently in- 
volves the supraorbital branch of the trigeminus; also the occipital, the 
intercostals, sciatic and brachial nerves may be affected. Such forms 
of malaria are called "masked malaria." In this form there is no fever 
and as a rule it is very hard to diagnose. A blood analysis should be 
made to confirm the diagnosis. In some cases one or more stages in the 
paroxysm of intermittent fever is omitted; this is especially true with the 
chiU, in which case it is termed "dumb ague. " Malarial cachexia is also 
sometimes called "dumb ague" and both are found among the older in- 
habitants of malarial districts. Persons living in malarial districts are 
sometimes affected with constipation, headache, loss of appetite, nausea, 
vomiting and a languid feeUng; this is called "latent intermittent fever." 
Frequently "bihous attacks" are of a malarial origin. 

Malarial Hematuria. — Hemorrhages may occur from the mucous 
membrane in all severe and persistent types of malarial infection. It is 
a frequent symptom of the pernicious variety. The parasites destroy 
the red blood corpuscles; this is the cause of the hemoglobinuria. Pros- 
tration and anemia are marked. In blackwater fever, a tropical dis- 
order, acute hemolysis, is the cause of the hemoglobinuria. 

Diagnosis. — This is usually easy. The characteristic stages of the 
paroxysms, the periodicity, residence in malarial districts and the alter- 
ations in the blood will usually remove every doubt as to the diagnosis. 

Typhoid Fever may simulate malarial fever, but a careful analysis 
of symptoms and blood examination will differentiate. 

Prognosis. — This is almost always favorable under early and per- 
sistent treatment. The unfavorable symptoms are uremia, hemorrhage 
and marked jaundice. 



352 The Practice of Osteopathy 

Treatment. — Attention should first be given to prophylactic 

measures. Environment, isolation of the patient, and destruction of 
the mosquito are important considerations. Cases of malarial fever 
present distinct lesions in the vertebrae and ribs corresponding to the 
vasomotor nerve supply of the spleen and liver. The most common 
lesion found is a marked lateral deviation between the ninth and tenth 
dorsal vertebrae and a consequent downward displacement of the tenth 
ribs. A disturbance will always be found in the region of the eighth to 
the eleventh dorsal vertebra, inclusive, or in the corresponding ribs on 
either side. These lesions undoubtedly derange the vasomotor nerves 
to the spleen and liver; thus permitting a weakness or lowered resistance 
of the system, especially of the blood. The blood resisting powers are 
lessened, probably on account of the spleen being affected, as it is an elab- 
orating gland of the blood; and the liver's action is somewhat dependent 
upon the action of the spleen; besides, the Uver is a secretory and excre- 
tory organ. 

The principal osteopathic treatment given in cases of malarial 
fever is correction of these subdislocations, and thorough treatment to 
the hver and spleen directly. Ligon observes that when the case does 
not respond quickty to treatment it is very Hable to be of considerable 
duration, although in the majority of cases the disease is controlled from 
the third to seventh day; the most constant lesions found are from the 
eighth to tenth dorsal and also the fourth lumbar. 

During the chilly stage thorough treatment of the vasomotor nerves 
in the upper cervical, the upper dorsal, the lower dorsal and the lumbar 
regions is indicated; tliis treatment is given to equalize the vascular sys- 
tem. 

During the hot stage the same treatment as in the chilly stage 
should be given to control the vascular system; besides a thorough treat- 
ment of the spleen and liver is necessary. Sponging the body with water 
will be of some aid in reducing the temperature. 

During the sweat stage thorough inhibition at the superior cervical 
gangUon to control the sweat center of the medulla, and treatment at the 
upper dorsal and first lumbar to control auxiHary sweat centers are in- 
dicated. 

The bowels should be kept active. When in a comatose form and 
when internal temperature is high, place the patient in a bath. In chron- 
ic cases, change of climate with thorough systematic treatment will 
usually result in recovery. 



The Practice of Osteopathy 353 

Tete\ of Louisiana, makes the following interesting statement: ''A 
specific osteopathic treatment given within an hour before the expected 
chill is a specific cure for malaria." He follows this up by treating on 
the third, fifth, seventh, fourteenth, and twenty-first days, on account 
of the tendency of the return of an attack on those days. His observa- 
tion of the value of treatment just before the attack is borne out by a 
report by Teall^ where the case was cured in one treatment, but the 
lesion was as high as the fourth dorsal. N. Chapman confirms this as 
being her experience in many cases. The spleen has been observed by 
Bandel to become engorged and upon emptying there would follow a 
rise of temperature of one fourth to half a degree. This has also been 
spoken of by Tucker as the ''splenic wave." Ligon makes the state- 
ment that where the osteopathic lesion (the predisposing cause) has 
been of long standing prior to the attack, and as a consequence hard to 
correct, it is difficult to shorten the malarial attack. 

This would emphasize the point that the essential treatment must 
be a thoroughly readjustive one, and that stimulatory and inhibitory 
work can only palliate. This is borne out by several practitioners who 
have had considerable experience. Very satisfactory results follow 
adjustment of the seventh to tenth dorsals. 

Quinine has been accepted by medical authorities as a specific for 
malaria. It is supposed to act directly upon the intracorpuscular hema- 
tozoa. That it is not infalHble is shown by the numerous cases which 
come to the osteopath, suffering from both the disease and the quinine. 
And even drug authorities state that other treatment is also required. 
It has remained for Dr. Still to demonstrate that excellent results follow 
osteopathic treatment in malaria. Frequently a single treatment has 
been sufficient to free and regulate the body fluids and forces so 
that the parasite was rendered inert, and this treatment was directed 
chiefly to the fourth and twelfth dorsals. Whereas the osteopath recog- 
nizes and appreciates the importance of micro-organisms as exciting and 
determining factors in many diseases, still he values them as secondary 
factors only and relies primarily upon removing the predisposing and 
true etiologic factors, so that nature's forces may not be obstructed and 
thus predominate. Osteopathic etiology and pathology has shown so 
conclusively, in a large number of cases, that the existence of micro- 
organisms is dependent upon devitalized tissue, whether the tissue is a 
local one or a circulating one, as the blood; and just so soon as the ana- 

1. Journal of Osteopathy— Prize Article July, 1906. 

2. A. O. A. Case Reports— Series I. 



354 The Practice of Osteopathy 

tomical is adjusted the physiological will function and antitoxic and 
antimicrobic substances are secreted. 

"When the patient has the quartan parasite, as soon as the tempera- 
ture begins to fall I give him from two to six ounces of red meat juice, 
extracted from rare beefsteak, sometimes as much as five pounds in the 
first twenty-four hours following the chill. In almost all cases of quar- 
tan malaria the blood is built up sufficient!}^ by the time they reach the 
second cycle to pass without the paroxysm, or chill. By the time for 
the third cycle, which is the seventh day, I always have built up the pa- 
tient's resistance so as to enable him to pass by this cycle without any 
symptoms of malaria whatever. In cases of double or triple I find the 
same treatment causes about the same results. I do not give any other 
diet, except dry toast if they eat the beef instead of taking the juice. 
If they can take the steak I prefer their taking it, but almost all cases 
prefer the juice. * * * The treatment for the tertian type of malaria 
is practically the same as the treatment for the quartan. 

"The estivo-autumnal type of malaria differs from the quartan and 
tertian types; first, in that the paroxysms are, as a rule, much more 
irregular; second, they are much longer in duration; third, the chiUs are 
more frequently absent; fourth, the fever is often irregular, intermit- 
tent, remittent, or continuous in character. This type very often takes 
the form of blackwater or hemoglobinuric type with hemorrhagic sjmip- 
toms, with hemorrhage from nose, gums, and bowels. The first thing to 
do in a case of hemorrhagic malaria is to put an ice bag on the abdomen, 
which will tend to control the hemorrhage from the kidneys. Give the 
patient all the red beef juice you can get him to take, provided he has 
not developed a very sick stomach; if so, give him high sahne enemas and 
in one-half hoiu- give him four ounces red beef juice per rectum. Re- 
peat the feeding per rectum in four hom'S. As soon as he can retain 
anything on stomach give him aU the juice he can take comfortably. 
Treat the Hver thoroughly — at least three times in the first twenty-four 
hours. At the end of thirty-six hours the yellow cast will be very much 
fighter, which is a sure sign that the patient is getting better. Watch 
the urine closely. The third day there may occur a suppression. If 
so, give strong stimulation to the renal plexus through the abdomen, and 
be sure there is a thorough relaxation of the dorsal and lumbar muscles. 

"It is an estabhshed fact that people in the malarial districts eat 
very fittle beef. I find that ninety-nine per cent of the cases of malaria 
never eat it, or when they on rare occasion do, it has been so overcooked 
that all the blood-building substances have been destroyed. The beef 



The Practice of Osteopathy 355 

raw would be better in my opinion; although, the possible chance of 
getting a tapeworm or animal parasite is so considerable that I would 
advise that the beef should be heated to 250 degrees." — E. C. Arm- 
strong, Clinical Osteopathy. 

Septicemia 

This term is applied to any toxic condition caused by the invasion 
of the blood by pathogenic micro-organisms, with or without any visible 
site of infection . 

Etiologically, the micrococci, streptococci, pneumococci, or staph- 
ylococci, as to frequency, in order named, are the cause. The infection 
is usually introduced by a wound, of any degree of severity. The uterus 
is a frequent seat following miscarriage, parturition or operation. The 
virus may be absorbed by the mucous membrane. It may also arise 
from infection of the deeper tissues. Pathologically, the changes are 
not marked, but consist in brownish color of the muscles, ecchymotic 
spots in the pia mater and dark appearance of the blood, which is also 
less coagulable. Spleen, Hver and lymphatics are enlarged with some 
changes in the other organs. 

Symptoms. — The incubation period is from four to six days and 
the onset is gradual, though often announced by a distinctive chill, fol- 
lowed by a profuse sweat. The most common type is the continuous 
form of fever, which may, in morning remissions, become subnormal. 
Pulse is rapid at the beginning, but as cardiac failure comes on, it be- 
comes weaker. In the earlier stages there may be vomiting with diarrhea 
later. There are punctiform hemorrhages of the skin and possibly other 
eruptions. Blood examination will settle any doubt as to diagnosis. 

Prognosis is good in large percent of cases and depends upon the 
general health of the patient. 

Treatment. — "Incise and drain the infected part; if possible, 
apply hot boracic acid compresses or keep part suspended in hot boracic 
acid solution. Osteopathic treatment will aid materially in stimulating 
and strengthening the patient. Bowels, kidnej^s and skin must be kept 
active. Normal salt solution, hypodermically or per rectum is of value. 
Diet should be liquid, fruit juices, broths, soups until temperature has 
remained normal twenty-four hours then milk, eggs etc., in gradually in- 
creasing amounts until general diet is restored. Amputation of the part 
may be necessary. " — L. E. Browne. 



356 The Practice of Osteopathy 

Pyemia 

A febrile disease arising from an invasion of the blood by pathogenic 
bacteria, wherein sepsis and multiple abscesses occur from absorption 
and metastasis. 

Etiologically, the cause may be traced to various specific organisms 
which enter the blood stream and produce thrombophlebitis. From 
these points and from other bacteria, new foci are estabhshed. Oc- 
casionally the lymphatics carry the germs. The disease maj^ also start 
from ulcerative endocarditis or when the appendix is infected. 

Pathologically, thrombosis of the vein may take place in any 
region. Abscesses may form in the lungs, Hver, spleen or other internal 
organs. The small abscesses may unite and form a large one. The 
skin presents eruptions and hemorrhagic extravasations, while there 
may be ulcers of the mucous membrane, also the serous surfaces may 
be purulently inflamed. The muscles, subcutaneous and osseous tissue 
occasionally have abscesses. Ulcerative and suppurative heart lesions 
occur. 

Symptoms. — The incubation period is short. There may be 
slight fever, but commonly a chill is the first symptom, which may re- 
occur for some time. The fever is either remittent or intermittent and 
when the temperature is low, sweating is a feature. The pulse becomes 
rapid and weak, when the disease is severe; breathing becomes difficult. 
Skin symptoms, such as eruptions and pustules, generally occur. In a 
word, there is a general intoxication. There is a lessened number of red 
blood corpuscles and leucocytosis is a characteristic. In grave cases, 
delirium and coma are present. 

Diagnosis.^The history of the case and symptoms will usually 
render diagnosis easy, although care is necessary to determine from 
septicemia. Malaria, typhoid and acute tuberculosis must be excluded. 

Prognosis. — Much depends on asepsis and surgery but on the whole 
it is unfavorable. 

Treatment. — Surgical interference and treatment as outhned 
under septicemia is the only hope. 

Dengue 

(Breakbone Fever) 
Definition. — An acute infectious disease; characterized by a double 
febrile paroxysm, severe pains in the muscles and joints and sometimes 
a skin eruption. 



The Practice of Osteopathy 357 

Etiology. — It is a disease of tropical and subtropical regions. Un- 
hygienic conditions predispose to an attack. During an epidemic a 
single attack is the rule. The disease spreads from place to place along 
the lines of travel, attacking both sexes, and all ages. It occurs in epi- 
demics, practically affecting every one. The specific germ has never 
been isolated as it is probably ultra-microscopic but there is no doubt 
but that it is carried by the mosquito Culex fatigans. 

Symptoms.— The incubation period lasts about four days. The 
onset is abrupt with a slight chill, headache, and extreme pain in the 
joints and muscles, of a boring or breaking character. The joints be- 
come red, swollen and painful. The fever rises gradually to 103 or 106 
degrees F., or over. The pulse is rapid and full and the respirations are 
much quickened. The face is flushed, the tongue coated, the appetite 
is lost, and slight nausea occurs. "Black vomit," similar to that of 
yellow fever, has been observed in this disease. Hemorrhages from 
various organs may occur and the IjTiiphatic glands are swollen. The 
urine is scanty and the bowels constipated. Febrile albuminuria and 
delirium are rare. 

At the end of three or four days the temperature falls and there 
is a period of remission; the patient is free from pain, but profoundly 
prostrated. During this time the eruption generally appears, but is 
never constant in character. After a remission of two or three days, 
the symptoms reappear and a second febrile paroxysm sets in. This is 
usually milder and shorter than the first, lasting two or three days, when 
convalescence begins. The duration is, according to medical writers, 
from seven to ten days, and convalescence slow. Death seldom occurs, 
so practically no pathological changes have been recorded. By osteo- 
pathic treatment, E. B. Ligon has been able to confine the attack to 
four or five days duration; this is confirmed by the experience of N. Chap- 
man. 

Diagnosis. — During an epidemic the disease attacks all classes alike, 
and the distinct remission renders the diagnosis comparatively easy. 
An occasional case might be mistaken for acute rheumatism, but the 
absence of any glandular swelling or eruption, while the pain is more 
closely limited to the joints, will aid in the diagnosis. Care has to be 
taken that yellow fever is not mistaken for dengue. 

Treatment. — The indications of the treatment arc to maintain 
the patient's strength and to treat the leading symptoms as they arise. 
The s(!verity of an attack can probably be lessened at the start by strong 
and thorough treatment of the sub-occipital, upper dorsal, lower dorsal 



358 The Practice of Osteopathy 

and lower lumbar regions, respectively, so as to control the large vascular 
areas by means of the vasomotor nerves of the cranial region, of the lungs, 
of the splanchnic region, and of the lower hmbs, thus equahzing the 
entire vascular sj^stem. Ehmination should be pushed and the excre- 
tory organs stimulated. Ligon has observed that the cervical and lum- 
bar regions are especiallj^ tender on the second day and the lower dorsal 
region on the tliird day. The most severe symptoms disappeared within 
a few hours after treatment and the attack was markedly shortened. 

The high fever may be treated by the usual methods and by the 
external application of cold water. The pain is to be controlled, accord- 
ing to the region affected, by a correction of parts impinging upon the 
nerve tissues and by strong inhibition. The entire spinal region should 
be kept constantly in a relaxed condition, as far as muscular contractions 
are concerned. Particularly should the treatment be extensive along 
the spine during prostration. N. Chapman, in addition to the osteo- 
pathic treatment, has the patient drink considerable hot water; also 
employs the hot bath. The treatment frequently shortened the attack. 
During the entire attack of the disease, the patient should be kept in bed 
and a carefull}^ regulated diet administered. Relapses are not infrequent. 
A suitable change of air may hasten convalescence. 

Cerebrospinal Meningitis 

Debnition. — A specific, infectious disease caused by the diplococcus 
intracellularis meningitidis, occurring sporadically and in epidemics. It 
is characterized by inflammation of the membranes of the brain and 
spinal cord and an irregular course. 

Osteopathic Etiology and Pathology. — The specific exciting 
cause of the cerebi-ospinal meningitis is due to the diplococcus intra- 
cellularis meningitidis of Weichselbaum. Lesions are found in the 
vertebra? corresponding to the cervical and dorsal enlargement of the cord, 
as well as in corresponding deep muscles; also, as is well known, the mus- 
cles of the entire back are severely contracted, especially of the cervical, 
upper and lower dorsal regions. IVIore commonly it attacks the young, 
although it may occur at any age. Overexertion, exposure, overcrowded 
and illy-ventilaied buildings, barracks and tenements, and depressing 
mental influences are predisposing causes. Manj^ times the disease 
occurs among the poorer classes. Sometimes the disease prevails in the 
country rather than in the city. 

In cases that prove speedily fatal there may be no characteristic 
changes; simply marked congestion. Other cases in which death occurs 



The Practice of Osteopathy 359 

after the disease has been fully developed, there is found every degree 
of inflammation from slight hyperemia to suppurative changes. There 
can be no doubt that the osteopathic lesion, as vertebral and rib lesions 
and deep muscular contractions, affects the circulation of the meninges 
of the brain and cord and thus favors the invasion of the specific micro- 
organism. The arteries, veins and sinuses are greatly engorged. The 
walls of the ventricles soften and the ventricles contain serous exudate. 
The brain matter may be congested and softened in spots. In the spinal 
membranes similar changes take place and at times there is extravasation 
of blood. The changes are more marked on the posterior than the 
anterior surface of the cord. Abscesses sometimes form. The exudate 
may follow the lymph sheaths of the cranial nerves, especially the audi- 
tory and optic. In long standing cases the membranes become thick 
and adherent and areas of softening or atrophy of the cortex develop. 
The thickening and adhesions of the membranes may cause various 
symptoms for months or even years after recovery from the acute dis- 
order. 

The spleen may be normal in size, but when the fever has been 
intense, it is apt to be slightly enlarged. Bronchitis, pneumonia, endo- 
carditis and pleurisy may occur. The liver may become hyperemic 
and the kidneys congested. 

Symptoms. — The prodromes vary, although the onset is apt to be 
sudden with a decided chill; headache; vomiting, and pain in the neck 
and back, which is usually severe, but may be so slight as not to be noticed 
by the patient. The temperature rises to 101 to 102 degrees F., in most 
cases. However, it may rise to 105 degrees or 106 degrees and even to 
108 degrees in fatal cases, and the pulse is full. Hyperesthesia, photo- 
phobia, and dread of noise are apt to be prominent symptoms. The 
muscles of the neck and back become rigid, and there are pains in the 
limbs. Orthotonos occurs more frequently than opisthotonos. Con- 
vulsions are common in children. There may be paralysis, especially of 
the muscles of the face and eyes. Delirium usually appears early; it 
may be mild, but it is often maniacal. The bowels are usually confined, 
though there may be diarrhea. There is moderate and constant leuco- 
cytosis and jaundice has been met with. 

The urine is sometimes albuminous, and sugar has been noted in 
rare cases. The urine may be increased, but more often it is lessened 
as in other infectious diseases. 

Herpes faciaUs occurs shortly after the onset in more than half the 
cases. The contents of the vesicles may be purulent and one or two may 



360 The Practice of Osteopathy 

coalesce. The petechial eruptions are occasionally numerous and cover 
the entire skin; they do not disappear upon pressure and the number of 
spots varies greatly. Other eruptions as sudamina, ecthyma, pemphi- 
gus, urticaria, erysipelas, rose colored spots, and gangrene of the skin 
(rarely) have been met with. 

In cases that are rapidly fatal, the onset is sudden, usually with 
violent chills, headache, depression, and in a few hours coma and col- 
lapse, which are soon followed by a fatal termination. The tempera- 
ture may rise slightly, but it is often subnormal. The pulse is feeble; 
breathing is labored. These cases occur more frequently at the beginning 
of an epidemic. They occasionally occur sporadically. 

The abortive form terminates abruptly after the development of 
one or more pronounced, characteristic symptoms. 

The mild form can only be recognized during the prevalence of an 
epidemic. The symptoms are very mild; slight vomiting, little or no 
fever, headache and slight pain in the back and limbs. 

The intermittent form is characterized by increase in the fever 
every day or second day. The strict periodicity seen in malaria is not 
observed; the fever resembles that of pyemia. 

In the chronic form the condition may persist for weeks or months. 

Complications. — Pneumonia (lobar and lobular) is a frequent com- 
plication. Pleurisy, pericarditis, parotitis, arthritis, enteritis, optic 
neuritis and otitis media may be other complications. 

Sequelae. — Blindness, deafness, keratitis (rai'ely), persistent head- 
ache, chi-onic hydrocephalus, abscess of the brain, mental feebleness, 
defective articulation, aphasia, and paralysis of certain cranial nerves 
or of the lower extremities have occurred. 

Diagnosis. — Typhoid fever begins slowly and is unaccompanied 
by vomiting, muscular spasms or rigidity, or hyperesthesia. In ty-, 
phoid the fever is higher and there is a characteristic temperature curve. 
Widal's test will confirm. 

Tubercular meningitis is not epidemic and has no characteristic 
eruption. It is usually less sudden in its development and is invariably 
fatal. Retraction of the neck, muscular spasms of the legs and arms 
are not so marked as in spinal meningitis. 

Pneumonia may be comphcated with meningitis, especially when 
the meningitis is confined to the cerebrum. If the case is not seen early, 
it is almost impossible to say which is the primary affection, as pneumonia 
may have meningeal complications or cerebrospinal meningitis may be 
associated with pneumonia. There will be motor spasms and tremors, 



The Practice of Osteopathy 361 

but the head is rarely retracted, and there is less myalgiac pain than in 
cerebrospinal meningitis. 

Prognosis. — This varies according to the severity of the type. 
It is a grave disease. Cases have been treated successfully by several 
osteopaths. The duration is very variable — from two or three days to 
weeks or even months, but probably in all cases this time can be ma- 
materially shortened by judicious osteopathic treatment. Convales- 
cence is very slow and relapses are prone to occur. 

Treatment. — The osteopathic treatment of cerebrospinal menin- 
gitis requires most thorough, but very careful, work along the spinal 
column, especially the cervical region and the region of the dorsal en- 
largement of the spinal cord, in relaxing and keeping relaxed the deep mus- 
cles on either side of the spine and correcting the derangements of the 
vertebrae, particularly in the upper cervical spine. Such treatment 
has a marked effect on the circulation of the spinal cord and brain. Prob- 
ably, a large amount of the work along the spine, in all cases where mus- 
cles are relaxed, has a direct effect upon the circulation of the spinal 
cord. This treatment constitutes the, primary osteopathic work in 
cerebrospinal fever and should be frequently apphed until a cure is ob- 
tained. Even in chronic cases where limbs have been greatly affected by 
pressure upon the nerve centers, due to a thickened membrane, contin- 
ued osteopathic treatment along the spine has had a marked effect in 
absorbing the pathological condition and restoring strength. 

The preceding spinal treatment is also a very great safeguard in 
keeping the various viscera healthy and thus preventing complications. 
In all constitutional diseases of an acute nature, it is a wise precaution 
to thoroughly examine the entire length of the spinal column at each 
visit; and if such precaution is taken many serious complications will 
never occur that might otherwise have taken place. 

The patient should be isolated in a somewhat darkened room, and 
care taken that the disease is not allowed to spread. Keep the patient 
upon his sides as much as possible. The diet should be a nutritious 
one of milk and broths. They should drink freely of water. Cold to 
the head and spine will be of service in controlling the inflammation; 
it should be apphed with an ice-cap and a spinal ice-bag. Sponging the 
bod}^ should be employed if the temperature is above 102° F. The gen- 
eral bath, as in typhoid fever, may be employed if practicable. Direct 
treatment to the bowels, kidneys, hver and spleen should be given at 
each treatment. 

Lum])ar puncture and the Flexner-Jobling serum are considered of 
value by those who have had an extensive experience. 



362 The Practice of Osteopathy 

Diphtheria 

Definition. — An acute, infectious disease, caused by the Klebs- 
Loeffler bacillus, and characterized by a membranous exudation on the 
mucous membrane of the fauces, larynx or nose, and by constitutional 
s^Tuptoms. The presence of the Klebs-Loeffler bacillus distinguishes 
tme diphtheria from any other form of membranous inflammation. 
The term diphtheroid is applied to all such forms as are not due to the 
Klebs-Loeflier bacillus. 

Osteopathic Etiology and Pathology. — The exciting cause is 
the Klebs-Loeffler bacillus. The predisposing cause is obstruction to 
the circulation of the pharjaix and tonsils by sub-dislocations of upper 
cervical vertebrae, and even the lower cervical and upper dorsal, and 
severely contracted deep muscles of the neck. The stasis of blood favors 
the growth of the bacillus. 

Link^ says: "The cause of nasal, pharyngeal or laryngeal diph- 
theria is obstruction of the blood and lymph through the neck and the 
obstruction occurs as a result of lesions in the cervical region, affecting 
the cervical sympathetics, or lesions in the upper thoracic region whence 
the vasomotor fibers arise. A derangement of the veretbral articulation 
of the first rib is usually found. .(This affects the stellate gangUon and 
fibers of the sympathetic chain). These lesions cause a condition of 
lowered vitaUty of the mucosa of the nose and throat; the abnormal 
secretion favoring the rapid multiplication of the Klebs-Loeffler bacillus — 
the exciting cause of the disease. " 

Dr. Still believed that, among other lesions, contracting of tissues 
involving the scaleni and disturbing the relations of the first rib with 
the clavicle and vertebra are causative factors. The constitutional 
symptoms are produced by the toxins generated by the bacillus and 
absorbed from the diseased spots by the lymphatics and blood-vessels. 
The bacillus is non-motile and does not usually penetrate the mucosa, 
but remains very near the site of the local changes although there are in- 
stances where it may enter the blood and other tissues. The bacillus is 
very resistent and can maintain an existence for months outside of the 
body. There is great variation in the virulence of the Klebs-Loeffler 
bacillus; it has been found in healthy throats, and sometimes the bacillus 
may exist in the throat after an attack of diphtheria for months after 
all the membrane has disappeared. It has also been found in cases of 
simple catarrhal angina without membrane, and in simple tonsilUtis 

1. E. Link, Diptheria— The Bulletin, 1905. 



The Practice of Osteopathy 363 

Of the bacteria associated with the bacillus of diphtheria, the strepto- 
coccus pyogenes is the most common and probably the most active. 
The staphylococcus, micrococcus lanceolatus and bacillus coli communis 
are also found. 

The contagion is communicated, as a rule, through the air, by means 
of fomites from the membranous exudate or discharges from the diph- 
theritic patients, or during convalescence, from secretions of the nose 
and throat. Infected milk may cause the disease. Most cases occur 
in childhood, between the second and seventh year. The disease is 
most prevalent in the cold autumn and spring months. It is most fre- 
quently met with in temperate and cold climates. Defective drainage, 
catarrhal conditions of the throat, enlarged tonsils, general weakness, 
and feeble resisting power are predisposing factors. One attack does 
not confer immunity from another, but rather predisposes to a second. 

The false membrane is usually found on the tonsils, the pillars 
of the fauces and the pharynx, and in fatal cases it may be extensive and 
involve the uvula, the soft palate and the posterior nares, and even the 
trachea and bronchi. At first this membrane is yellowish white, but 
later may become gray; it is more or less adherent and when torn off 
leaves a raw surface. The diphtheritic poison coming in contact with 
the throat leads to, first, a necrosis or death of the epithelial cells, es- 
pecially the more superficial, and the leucocytes. The second change 
is the hyahne transformation, and simultaneously coagulation; hence 
the term coagulation-necrosis. The irritation produced by the bacilK 
causes a migration of leucocytes and these are destroyed and undergo 
hyahne transformation. This process proceeds from without inward 
and is. usually superficial, and the necrosis may be extensive, involving 
the deeper tissues, causing ulceration and a gangrenous condition of 
the parts. The erosion of the tonsils may be so severe as to attack the 
carotid artery. The lymphatic glands are considerably swollen. The 
spleen is commonly enlarged. The kidneys show parenchymatous 
changes. The blood is dark and fluid. Fatty degeneration of the heart 
is not infrequent. Sometimes fibrinous coagula are found in the heart. 
Capillary bronchitis, catarrhal pneumonia and areas of coUapse are 
almost constantly found on examination of the lungs in fatal cases. The 
urine is typically febrile with early albumin and often tube casts and 
renal epithelium. Th(! blood shows an excess of red blood cells which 
may reach 7,500,000. Hemoglobin is slightty reduced. There is con- 
siderable anemia during convalescence depending upon severity of tox- 
emia. 



364 The Practice of Osteopathy 

Symptoms. — The incubation period varies from one to ten days, 
usually two or three days. According to the location, diphtheria may be 
divided into pharyngeal, laryngeal and nasal forms. 

In Pharyngeal Diphtheria, which is most common, there is first a 
slight chill or chilliness, followed by fever and sore throat, both of which 
increase rapidly. The throat is swollen and red and the patient complains 
of difficult swallowing. The membrane begins on the tonsils in the form 
of grayish- white patches; it then spreads from the tonsils to the soft 
palate, sometimes covering the uvula. The cervical glands are swollen 
and tender. The neck muscles are contracted and somewhat difficult 
to relax. The temperature rises to 102 or 104 degrees F. The pulse is 
rapid and feeble, ranging from 120 to 140. There is loss of appetite. 
There is more or less prostration depending upon the gravity of the con- 
stitutional symptoms. The average duration is from one to two weeks. 

Laryngeal Diphtheria (Membranous Croup) may be secondary 
to extension from the fauces or it may be primary. At first there is 
slight hoarseness and a harsh, metallic, ringing cough. These symptoms 
may persist for a day or two, when the child suddenly becomes worse; 
there is marked dyspnea and the hps and finger tips become fivid. The 
child soon becomes very restless. The temperature may be sfightly 
above normal and the pulse increased in frequency. In favorable cases 
the dyspnea is not very marked and the child probably will have only 
one or two paroxysms, when it will fall asleep and wake in the morning 
feeling very comfortable. The next night, however, the attack may be 
more pronounced. In extreme cases death may result from suffocation. 
In some cases the suffocation is slower and results from extension of the 
membrane downward into the bronchi. Dr. Still found same conditions 
as in diphtheria, but also the hyoid is involved with the superior laryn- 
geal nerve. The sacral and lumbar nerves are also involved. He always 
emphasized chilHng of gluteal region as a cause for croup and that heat 
should be applied at the inception of the disease. 

Nasal Diphtheria is generally secondary, but it may be a primary 
affection. In many cases no membrane is found; in others there may be 
a pseudo-membrane formed in the nose, but there is absence of any sys- 
temic disturbance. The Klebs-Loeffler bacillus is sometimes present in 
these membranes. Nasal diphtheria may be a very grave disease — 
the constitutional symptoms being great prostration, high fever, marked 
glandular swelling, irritating and offensive discharges from the nose, and 
epistaxis. Inflammation occasionally extends through the tear duct to 
the conjunctiva. 



The Peactice of Osteopathy 365 

A diphtheritic membrane may grow where the skin has been cut or 
bruised, but the bacillus cannot live on normal skin. It flourishes on a 
raw, moist surface and membranes have grown on the lips, tongue, vulva, 
glans penis, and on ulcerative surfaces and wounds. Diphtheria occurs 
occasionally in the conjunctiva and the external auditory meatus. 

It should be remembered that there are many atypical forms of diph- 
theria. Bacteriological examination should always be made in suspicious 
and puzzling cases. 

The complications of diphtheria are nephritis, hemorrhages, rashes, 
capillary bronchitis, pulmonary collapse, catarrhal pneumonia, myo- 
carditis, arthritis, otitis media, and paralysis. 

Diagnosis. — The presence of the Klebs-Loeffler bacillus will at 
once decide the diagnosis of diphtheria. 

Prognosis. — The prognosis should always be guarded. The nasal 
and laryngeal forms are always grave. The causes of death are involve- 
ment of the larynx, septic infection, heart failure, bronchopneumonia 
during convalescence, and rarely, uremia. 

Treatment.— Hygienic and prophylactic measures are important. 
A room should be selected that is ventilated and exposed to the sun- 
light. All unnecessary articles of furniture should be removed. Great 
care must be taken against the spread of the disease. Always isolate 
the patient and disinfect everything that has come in contact with him. 
The greatest danger Hes in the spread of the disease during convalescence 
and in the ambulatory form, when patients are about and coming in 
contact with individuals, especially children with catarrhal conditions 
of the nose and throat. The physician should be careful about disin- 
fecting himself. 

In view of the fact that many osteopaths have treated successully 
numerous cases of diphtheria and that the osteopathic treatment is 
peculiarly indicated and effective, the probable requirement of anti- 
toxin (the use of which we do not feel called upon to discuss) would be. 
lessened. Relative to the antitoxin Osier says: "The principle of ac- 
tion depends on the circumstance that the blood-serum of an animal 
rendered immune, when introduced into another animal, protects it from 
infection with the diphtheria bacilH, and has also an important curative 
influence upon diphtheria, whether artificially given to animals, or spon- 
taneously acquhed by man." 

"The treatment of diphtheria by osteopathic methods is often a 
pleasure rather than a trial because of the success which rewards us for 
our efforts. There has been considerable discussion by the members oi 



366 The Practice of Osteopathy 

our profession regarding the methods to be employed in successful!}^ 
overcoming this disease, and many have expressed the view that since 
antitoxic serum is a physiological remedy, which naturally belongs to all 
schools of heahng, it should be employed by the osteopathic physician 
in cases of diphtheria. I have no objections to the use of the serum ther- 
apy by members of the profession who conscientiously feel that they 
need it in their practice to secure the highest success. However, I feel, 
on the other hand, that if they were well acquainted with the technique 
of the methods * * * they would not feel it to their advantage, from 
the standpoint of success, to use injections in a single case." — R. D. 
Emery, CHnical Osteopathy. 

The local treatment should be carefully, but vigorously, given. 
By proper treatment of the throat the extension of the disease may be 
prevented. The muscles about the thi'oat, especially the deep ones, 
should be thoroughly relaxed and the cervical vertebra) corrected if dis- 
placed. The vasomotor nerves to the blood vessels of the affected region 
require careful treatment at the superior cervical ganghon, and the cer- 
vical lymphatics from the atlas to the first rib should be closely watched. 
The nerves to control are the vagi, glosso-pharyngeal, spinal accessory, 
and sympathetic nerves to the pharyngeal plexus, and in cases of nasal 
diphtheria the fifth nerve has to be carefully treated. An external treat- 
ment to the pharynx will have the greatest effect on these nerves. An in- 
ternal treatment to the nerves of the soft palate will be of considerable 
service. The parts diseased should be disinfected and kept as clean as 
possible. Bichloride of mercury (1:4000) used as a spray will be found 
satisfactory, although there are several other disinfectants and germicides 
that may be used. Pellets of ice in the mouth will be a comfort to the 
patient. Cold appKed externally will be found best for the adult; heat 
externally is better for the child. 

Every possible means should be used to prevent the disease from 
spreading. One of the chief dangers of diphtheria is the spread of the 
disease to the larynx, trachea and bronchi. When the disease has ex- 
tended to these parts it presents all the sjrmptoms of true croup. The 
deep cervical muscles should be thoroughly relaxed to aid in reHeving 
the passive hyperemia and with a view of disorganizing the exudate. 
Attention should be given to the upper ribs, as interferences with the 
vasomot^or nerves of the mucous membrane of the trachea and bronchial 
tubes usually occur. Direct treatment over the larynx and local treat- 
ment through the mouth upon the soft palate will be of aid. A thor- 
ough relaxation of all the dorsal muscles, even as low as the tenth dor- 



The Practice of Osteopathy 367 

sal, should be given. Inhalations of slaked, freshly burnt Kme may be 
useful in loosening the exudation. In desperate cases tracheotomy or 
intubation of the larjmx should be performed. Willard^ says, relative 
to membranous croup: ''It matters not whether or not the laryngeal 
inflammation was immediately caused by a germ; it would not, nor could 
not, have been produced by such had there not been an unnatural con- 
dition of the circulation of and about the larynx. " 

A constitutional treatment should always be given with a view of 
preventing the spread of the disease from one organ to another and to 
prevent complications. The heart's action should be carefully watched 
throughout the entire course of the disease. Treatment of the spinal 
cord will guard against paralysis that sometimes follows the venous 
hyperemia of the vascular Hnings and substance of the brain and spinal 
cord. Pay particular attention to the upper dorsal region to prevent 
possible heart involvement. Post-diphtheritic paralysis seldom if ever 
occurs in cases that are treated osteopathically. This is a common 
sequela and is present in from 10 percent to 30 per cent of cases, appear- 
ing within three weeks of apparent recovery. Sometimes it is the only 
result to show diphtheria was present. It seems to follow use of anti- 
toxin rather frequently. Attention to the splanchnics and to the ab- 
domen directly will tend to keep the stomach, hver, kidneys, and intes- 
tines in a healthy state. The diet of the patient should consist of liquid 
food — milk, broths, meat juice, raw eggs and barley water. Let the pa- 
tient drink freely of water. Treatment of the rectum may be employed 
with benefit when the pharynx is greatly disturbed. 

Various sequelae and complications are best reheved or prevented, 
according to Link, as follows: "First, Umiting the production of toxins 
by a most thorough relaxation of the muscles of the neck, thereby favor- 
ing the unobstructed circulation of the blood and lymph; second, by the 
correction of lesions which affect the vasomotor of the head and neck; 
third, by spinal treatment affecting the vasomotor to the areas involved ; 
fourth, by increasing the activity of the excretory organs, by treatment 
in the splanchnic and lumbar areas, that the toxins may be more rapidly 
eliminated. In cases where laryngeal stenosis is marked and suffocation 
is imminent, intubation should not be delayed." Post-diphtheritic 
paralysis usually yields to osteopathic treatment. Apply treatment 
according to location. 

1. A. M. Willard, Membraneous Croup — Journal of Osteopathy, March, 1904 



368 The Practice of Osteopathy 

Dysentery 

(Bloody Flux). 

Dysentery is an infectious disease wherein the large intestine is in- 
flamed, with ulceration of the mucous membrane; is characterized, 
clinically, by frequent stools containing blood and mucus; fever and ex- 
haustion. Osteopathic lesions of an osseous character and deep mus- 
cular contractions of the lumbar region are always present. These in- 
volve the vasomotor nerves to bloodvessels and lymph channels. Catarrh 
of the intestinal tract is an important predisposing cause. The dis- 
ease usually occurs in the summer and autumn, and is more common i n 
hot, malarial regions, although it is found in various chmates. Unhygien- 
ic conditions are also important predisposing factors. In no disease 
more than dysentery does specific correction of the osseous lesion effect 
quick and satisfactory results. 

Acute Ileocolitis 

(Bacillary Dysentery) 

This is the variety most frequently found in temperate chmates. 
It occurs either sporadically or endemically. The Flexner bacillus is 
frequently found, as well as pus microorganisms. There are various 
strains of the bacillus. There is a catarrhal inflammation of part or 
the whole of the large bowel. Other forms may occur, as ulcerative 
and membranous. 

Osteopathic Etiology and Pathology. — Sudden atmospheric 
changes and simple irritants, such as unripe and indigestible food, are 
usually the immediate causes. The predisposing cause of acute catar- 
rhal dysentery is always found by the osteopath to be due to spinal de- 
rangements in the lumbar region. The lesion is generally a slight lateral 
deviation of a vertebra. It is generally found at the second or third lum- 
bar; still, the trouble may be found at any point in the lumbar section. 
The lesion involves vasomotor nerves to the intestinal mucous mem- 
brane, thus causing the inflammation. The drinking of impure water 
in itself may not be the cause of the disease, but is a favorable medium 
for the development of the organisms which may excite it. Dyspep- 
tic conditions and constipation seem to predispose to the disease. 

The mucous membrane is injected and swollen and often covered 
with bloody mucus. The folHcles of Lieberkuhn are enlarged from reten- 
tion of their contents, the result of the swelKng; the foUicles are often 
ruptured and the mucous membrane sloughs off in patches, forming ul- 



The Practice of Osteopathy 369 

cers. These may extend along the whole colon and frequently into the 
ileum. 

Symptoms. — Diarrhea is the most common initial symptom; 
the stools being copious and painless. The stools soon become small 
and frequent, covered with mucus and streaked with blood. These are 
passed with straining and tenesmus, accompanied by colicky abdom- 
inal pains of a griping character. Chills are rare. The tongue is furred 
and moist; later it becomes dry. Nausea and vomiting may be present, 
but not as a rule. There is fever and often excessive thirst. Later 
the stools become green in color, due to the bile which causes a burning 
sensation in the rectum. 

On examination there are found red blood-corpuscles and leucocytes, 
and large, round and oval epithelioid cells containing fat drops and vac- 
uoles. In mild cases, the course is about eight days ; severe cases subside 
within four weeks, but if the osteopatislc treatment is careful and spe- 
cific, the usual duration can generally be reduced one-half. 

Pi-ognosls. — The prognosis is generally favorable in the catarrhal 
form when the disease is treated properly. The previous general health, 
hygienic conditions, and sanitary surroundings are of great importance. 
When there is ulceration or membranes the prognosis should be guarded. 
The condition may become chronic. 

Treatment. — The bowel should be thoroughly washed out by 
warm water enema, several times, if necessary, to remove irritating 
material. Invariably a lesion of the spinal column is found at the third 
and fourth lumbars or near by. It is generally a subluxation, of a lateral 
nature, between these vertebrae : rarely is the lesion above or below this 
point. The treatment should be applied immediate^ and directly to 
this region. Time is valuable in these cases and one should go to work 
at once to correct the irritation. An attempt should be made at each 
treatment to correct the disorder. This should not be delayed by wast- 
ing time in relaxing muscles and inhibiting, for unsually this gives only 
temporary relief. When a sHght movement has been accomplished 
between disordered vertebrae, treatment should be stopped and results 
watched, because the adjustment may have released all obstructions 
or irritations causing the disease. In many cases, to get an anatomically 
correct spine is an impossibility, from the fact that the displacements 
may be of long standing and naturally the subluxated vertebrae have 
conformed themselves to some extent to their unnatural position. In 
other words, what has been lost in the position and relation of a vertebra 
may have been compensated by reducing the effect of the lesion to a 



370 The Practice of Osteopathy 

minimum. A lesion of this nature at the third lumbar impairs the in- 
nervation to the colon and consequentlj^ produces a stasis of blood in the 
mesenteric circulation, followed by inflammation, bloody discharges, 
cramps, etc. A single treatment is usually quite sufficient in milder 
cases. Other cases require treatment every few hours or thereabouts, 
until recovery. 

Treatment directly over the abdomen through the mesenteric cir- 
culation and glands is an effective treatment in most cases and especiall}^ 
when the attack is severe. It relaxes the tissues about the mesentery, 
thereby reUeving the stasis and freeing the circulation. The greatest 
care, however should be exercised in giving this treatment. 

The constant desire to defecate, that is common to many cases, is 
a very annoying S3miptom. Strong, thorough treatment over the sacral 
region, by inhibition over the sacral foraminae and by relaxing the tense 
muscles of the sacrum, will reheve this condition. In relaxing these 
muscles, place the whole hand against the muscles and push upward to- 
ward the occiput. This treatment inhibits the nerves to the rectum and 
lessens the tenesmus. 

Attention should be paid to the liver to keep it active. Washing 
out the large bowel with tepid water produces a sootliing effect, besides 
having a tendency to allay inflammation. The blandest of liquid foods, 
as peptonized or boiled milk, broths, beef juice, barley and rice, should 
be given. The patient should remain in bed until completely cured. 

Amebic or Tropical Dysentery 

This form prevails in the tropical and subtropical countries for the 
most part, and is caused by an animal parasite, the ameha dysenteriae. 
This is constantly found in the stools, the tissue of the intestine and 
also in the pus of the liver abscesses, which are secondary to dysentery. 
Amebae are sometimes found in the stools of healthy men, having prob- 
ably entered the system through the drinking water or uncooked food. 

Patliologically, the mucous membrane of part or whole of the large 
intestine is swollen. Round or irregular ulcers which undermine the mu- 
cous membrane, especially of cecum, ascending and pelvic colon, are 
found. In later stages there is infiltration of the connective tissue fol- 
lowed by necrosis. In some cases false membranes and sloughs are 
formed. 

Symptoms. — The onset may be either sudden or gradual, with 
a very irregular diarrhea, moderate fever, and copious, liquid stools, 
abounding with the amebae coli. The straining may be less severe and 



The Practice of Osteopathy 371 

persistent than in catarrhal dysentery and may be absent. Sometimes 
there is nausea and vomiting. 

Abscess of the Hver is the most common comphcation, which may be 
single or multiple. When single it usually involves the right lobe. Mul- 
tiple abscesses are small. The more recent abscess walls are necrotic; 
the older have whitish, smooth, fibrous walls. These abscesses do not 
contain pure pus, but a fatty and granular debris containing the amebae 
and a few cellular elements. Sometimes they extend into the lung. 

Diagnosis. — This depends upon severity of attack and general 
condition of the patient. Relapses often occur and the case may become 
chronic. Cases have been treated osteopathically with success. 

Treatment. — In this form of dysentery the treatment is largely the 
same as in acute ileocolitis. The spinal lesions affect the innervation 
to the intestine, thus producing a stasis in the circulation; this condition 
favoring, and in fact, inviting the retention of the ameba coK in the sys- 
tem at this point. 

The diet is the same as in other forms of dysentery. Rectal in- 
jections and hot apphcations to the abdomen are useful. In all cases 
where strong treatment has been given to the spinal column, a quieting 
treatment to the nervous system and an inhibitory treatment to the heart 
will be gratefully received by the sufferer. Both of these effects can 
be accompHshed at the same time by simple inhibition to the occipital 
nerves. The stools should be taken care of immediately and disinfected. 
Ice water enemas given frequently are reported as giving good results. 
For the tenesmus, inhibit strongly at 3d, and 4th, sacrals. 

Chronic Dysentery 

This is generally resultant from an acute attack, though the amebic 
form may be sub-acute from the onset. 

PathoIogically,the coats are generally thickened, especially the 
submucosa and the muscular coats being hypertrophied. Ulcers are 
usually present, although there are cases in which there are no ulcers. 
Cicatricial contractions sometimes follow and the cahbre of the bowels 
is reduced, strictures being rare. 

Symptoms. — There is a progressive loss of flesh and strength, 
little or no tenesmus, slight, colicky pain and extreme anemia. The 
stools contain mucus, at times blood, and the bowels move from two to 
twelve times a day. 

Diagnosis. — The history of the initial symptoms will estabhsh the 
diagnosis. It is not always possible to distinguish between chronic dys- 



372 The Practice of Osteopathy 

entery and chronic diarrhea. The duration is from a few months to 
several years, although osteopathic treatment has proven very eflEicient 
in many instances. 

Treatment. — Rest and a liquid diet are most essential. Foods 
that are easily assimilable and nourishing, with a minimum amount 
of residue, are required. Beef juice, beef peptonoids and peptonized milk 
are the types of food. Change of air, hygienic measures and environment 
are important. 

In cases that become chronic, the spinal column oftentimes exhib- 
its lesions above and below the lumbar region. Undoubtedly they are 
lesions of secondary importance in comparison to the lumbar lesions, 
but it is important that they be corrected. The treatment requires thor- 
ough, careful work of the disordered spinal column and lower ribs. Oc- 
casionally a slight kj^phosis is present in the dorso-lumbar region that 
demands persistent work in order to correct it. An occasional rectal in- 
jection is beneficial, especially in cases that have shght ulceration of 
the sigmoid flexure or rectum causing coKcky pains and a few loose stools 
in the morning, the patient being fairly comfortable during the rest of 
the day. 

Erysipelas. 

Definition. — An acute, infectious, specific disease, characterized 
by a pecuhar inflammation of the skin, due to the streptococcus erysip- 
elatis, with a tendency to spread. 

Osteopathic Etiology and Patliology. — Osteopathically, lesions 
are found to the vasomotor nerves and lymphatics of the affected area. 
Dr. Still gives lesions of the "inferior maxilla, the cervical vertebrae, the 
clavicles or the upper ribs" as specially important factors. These lead 
to congestion and predispose to infection. It occurs in epidemic form, 
especially in the late winter and spring. One attack predisposes to a 
second. Family predisposition exercises a slight influence. Abrasions, 
lacerated wounds, especially of the scalp, may be the starting point of 
an attack. Persons having skin diseases and wounds, and women who 
have been recently dehvered are Hable to be affected. Chronic Bright's 
disease, chronic alcohohsm, syphiUs, debility, phthisis, organic heart 
disease and unhygienic surroundings are predisposing causes. 

The specific virus is the streptococcus erysipelatis, which acts as 
a local irritant producing the dermatitis. These are found in the Ij-mph 
vessels and cutaneous connective tissue. The fever and constitutional 
symptoms are due to toxic agents. 



The Practice of Osteopathy 373 

It is an inflammation of the skin, and if uncomplicated, no other 
structures are involved. Subcutaneous and mucous tissues may be 
involved, but rarely; if so, there is apt to be suppuration. Visceral com- 
plications are of a septic character. Endocarditis, pericarditis, pleuritis- 
pneumonia, and nephritis are possible compHcations. 

Symptoms. — The incubation period varies from two to seven 
days. The onset is generally sudden with chill, followed by fever, 104 
or 105 degrees F. There may be nausea, headache, and pain in the 
back and Hmbs. The local inflammation of the skin follows, usually 
on cheeks and bridge of nose, or at site of an abraded surface. The 
area is red, smooth, and edematous. It spreads rapidly, the patch be- 
ing elevated above the surrounding tissue and tense. The swelUng 
may be so great as to close the eyes and distort the features. The cer- 
vical glands are swollen. The temperature continues high for four or 
five days and falls by crisis. The eruption begins to subside and a moder- 
ate desquamation occurs. If the disease takes a fresh start the fever 
again rises and continues as long as the disease spreads. There is usu- 
ally headache and sometimes delirium. The tongue is furred, and bow- 
els constipated and the urine scanty. As a result of intense infiltration 
the part may become gangrenous. Suppuration frequently occurs in 
facial erysipelas. The inflammation may extend to the mucous mem- 
brane of the throat and mouth. 

Diagnosis. — This is not difficult. The fever, the acuteness of the 
disease, the rapidily spreading eruption, and the constitutional dis- 
turbances will serve to distinguish it from all others. 

Prognosis. — This is usually favorable; healthy persons rarely die. 
Convalescence may be slow. 

Treatment. — Isolate the patient for the disease is contagious, and 
a third person may convey the virus. The poison may cling to clothing, 
furniture, etc. The physician should not take care of confinement cases.. 
A number of cases of erysipelas have been cured by correcting dis- 
orders in the region of the second, third, fourth and fifth dorsals. The 
lesions are principally subluxations of the ribs and severely contracted 
muscles. The disorder at the points named interferes with the vaso- 
motor nerves to the face, thus predisposing to an attack of erysipelas by 
allowing the micro-organism congenial tissue for its devastations. In 
many other cases derangements have been found higher than the upper 
dorsal, principally through the middle and upper cel-vical vertebrae. 
Lesions in these regions would also interfere with vasomotor fibres, es- 
pecially through the fifth nerve directly. 



374 The Practice of Osteopathy 

The treatments on the whole are to examine for lesions to the in- 
nervation of the affected region and remove them, besides giving special 
attention to the bowels, a nutritious diet, and absolute rest. In cases 
where there is much restlessness and insomnia, treat the upper cervical 
region, especially the deep posterior muscles . Locally, use cold water 
applications; adhesive strips applied near the inflamed area or tincture 
of iodine, may prevent the disease spreading. 

Yellow Fever 

Definition. — An acute, infectious disease, characterized by a febrile 
paroxysm followed by short remission and then relapse, jaundice, toxemia, 
suppression of the urine, and gastric hemorrhage. 

Osteopathic Etiology and Pathology. — While a specific germ is 
the cause of yellow fever, it has not as yet been isolated. Extended tests 
by United States Army surgeons in Cuba show conclusively that the in- 
fection is alone carried by the stegomyia fasciata^ but ''It remains some- 
what uncertain whether the mosquito is the sole means of transmission." 
(Anders). Season is the chief predisposing cause as the outbreak is us- 
ually in summer and a frost ends its spread. Immunity is generally con- 
ferred by one attack. Tucker" noted that all cases examined had liver 
lesions and that most of the patients were of the malarial or bihous type. 
Spinal lesions were -not marked in some cases, but when present were 
in the liver and renal areas. Tete^ believes it to be a virus secreted in 
the human organism under certain atmospheric and other conditions 
in certain types, i. e. people subject to hepatic and renal disturbances. 
He also says the vagus is an important factor. 

Pathologically, there is more or less jaundice and hemorrhagic 
extravasations under the skin. The blood serum is red-tinted, owing 
to the destruction of the red cells. The liver is pale and presents exten- 
sive fatty degeneration, with necrotic masses in and between the cells. 
The gastro-intestinal mucous membrane is swollen, congested and pre- 
sents numerous minute hemorrhages. The kidneys show parenchyma- 
tous inflammation. The spleen is not enlarged. The heart sometimes 
shows fatty degeneration. The stomach contains more or less of the 
"black vomit," which is a mixture of transuded serum and transformed 
blood pigment. 

1. See Dr. Still — Philosophy and Me'chanical Principles of Osteopathy. 

2. Journal of Osteopathy, October 1G05. 
■ 3. Journal of Osteopathy, October 1905. 



The Practice of Osteopathy 375 

Symptoms. — The incubation period varies from one to five days. 
The attack generally begins with a chill, fever, 102 to 105 degrees, head- 
ache and pains in the loins and legs. The pulse is accelerated, the face 
is flushed, the tongue is coated, the throat sore, the bowels constipated 
and the urine scanty and albuminous. Recent observers state that bile 
is present in most cases before the albumin is noted. Nausea and vom- 
iting may be present at the onset, but become more severe about the 
second or third day when the black vomit appears. The febrile stage 
or stage of invasion, lasts from a few hours to several days and is fol- 
lowed by a decline in the fever when the severity of the other s^Tnptoms 
abates. This is called the stage of remission and in favorable cases 
convalescence sets in or the patient may pass into the second febrile 
paroxysm. The temperature rises again, jaundice appears rapidly, 
nausea and vomiting return. The tongue becomes dry and coated. 
The stools are black and offensive, the urine is albuminous, scanty and 
may be suppressed; there may also be hematuria. Death may occur 
from exhaustion or from uremia. Recovery may follow the gravest 
symptoms, even when there has been black vomit. The duration of the 
entire attack covers about one week. Relapses sometimes occur. 

Price says there is a point in differential diagnosis in yellow fever and 
it is a symptom not met with in any other febrile affection. It is the 
progressive fall of the pulse rate during the congestive stage of the first 
sixty or seventy hours, i. e., a variation of from five to ten beats less each 
morning and evening. He adds, "As long as the kidneys are active there 
is but little to fear. " 

Diagnosis. — Remittent fever has not the deep jaundice, the clear 
mind, the black vomit, or the albuminuria of yellow fever. The en- 
larged spleen and the presence of the organism of Laveran in the blood 
in remittent fever will decide the diagnosis. Dengue is sometimes con- 
fused with yellow fever. 

Prognosis. — This is always a grave disease, and in its severe forms 
ver3^ fatal. Recovery, however, may occur after the severest symptoms 
have been manifested. Black vomit is not always a fatal sign. Enough 
cases have been treated osteopathically to state that osteopathy is 
particularly effective. Improved sanitation is doing much to reduce 
moi'tality. 

Treatment. — Pi-ophylactic treatment should be carefully carried 
out. All patients should be quarantined and carefully screened so they 
cannot be bitten by the mosquito and the disease spread further. Peo- 
ple that are not acclimated should keep away from infected districts. 



376 The Practice of Osteopathy 

All pools, cisterns and other places which can breed mosquitoes should 
be drained or screened. A systematic warfare should be waged against 
them. The patient must be put to bed at once and plentifully supphed 
with fresh air. Everything must be scrupulously clean — body and bed 
hnen. Use a tube for nourishment and a bed-pan for excretions as the 
patient must not make the shghtest exertion. 

Spinal lesions may or may not be found. They have been observed 
in the cervical, eighth dorsal and second lumbar. 

The treatment on the whole is s\anptomatic. The chills and fever 
of the first stage should be controlled by thorough work at the upper cer- 
vical, upper dorsal, lower dorsal and lower lumbar regions. Treat- 
ment at these points controls the superficial and deep vascular areas of 
the bod}' through the vasomotor nerves. The irritable stomach, dehr- 
ium and severe neuralgic pains of the head, back, epigastrium and Umbs 
are to be treated according to the conditions and severity of the symptoms. 
The kidneys and bowels should be watched carefully, and at the onset 
should be freely opened and control of the kidneys never lost. Let 
the patient drink freely of tater, which will aid. Hydrotherapeutic 
measures, as a cold bath or sponging, may be employed to aid in con- 
trolling the fever, the nervous symptoms, and the ehminative power of 
the excretory organs. Discontinue the use of hydrotherapy when a spon- 
taneous fall of temperature occurs. 

At the beginning of the first stage and during the stage of remission 
are the periods that the osteopath should do very effectual work by pay- 
ing particular attention to the four large vascular areas of the body, viz. : 
head, lungs, abdomen and legs. Treat the vasomotor nerves to these 
regions, thoroughly, as given in the treatment of the first stage. Dur- 
ing the third stage everything should be done that is possible to support 
the system. Ice slowly dissolved in the mouth will be of aid to an ir- 
ritable stomach. Hemorrhages and the various s\aiiptoms are to be 
treated as they arise. 

Good nursing, dieting, ventilation and keeping the skin, kidnej's 
and bowels active are the primary points to consider. During the per- 
iod of depression, the heart must be closely watched. The diet should 
be a Hght, Hquid one, of the nature of peptonized milk or fight broths. 
No food is recommended by some at the onset nor until the crisis is passed. 
Others feed during the stage of remission and give stimulants. Dur- 
ing the last stage rectal feeding is suggested if gastric irritabihty is pro- 
nounced. 



The Peactice of Osteopathy 377 

Tetanus 

(Lockjaw) 

Definition. — An infectious disease, caused by Nicolaier's tetanus 
bacillus, characterized by persistent, tonic spasms of the muscles with 
violent exacerbations. 

Etiology and Pathology. — The exciting cause of tetanus is a spe- 
cific bacillus which usually gains access to the system through some 
wound. The site of infection is the only place the germs are found. 

The disease is much more prevalent in some locaUties than in others. 
It is found in hot countries, as in India and the West Indies, far more com- 
monly than in temperate regions. Esposure to damp cold is one of the 
recognized causes, also those localities where there are rapid changes 
from cold. Such regions seem to produce conditions favorable to the 
existence and growth of the bacilli. 

Earth mould, particularly where putrefaction is taking place, as in 
soil that has been manured, is especially favorable to the existence of the 
bacillus. It is frequently found in the intestinal tract of the horse, so 
that the soil about stables is apt to contain the germs. The highh^ fer- 
tiUzed soil of France and Belgium rendered it a special menace to the 
wounded of the Great War. Antitetanic serum, according to all reports, 
was particularly efficacious. 

Wounds and abrasions of various kinds, particularly contused and 
punctured wounds of the hands and feet, favor the excitation of tetanus. 
When an open wound is present, the term traumatic tetanus is given 
to the disease; idiopathic tetanus when no wound is discoverable; 
tetanus neonatorum when it attacks infants — this form is usually due 
to insanitary conditions, especially the improper care of the umbilical 
cord; lock-jaw or trismus when the jaw alone is affected; cephalic 
tetanus when the throat and face is involved. 

Characteristic lesions have not been found in the cord or the brain. 
The bacilli develop at the site of the wound where the toxin is manufac- 
tured. The bacilli do not invade the blood and organs. The toxalbumin 
is one of the most virulent poisons known. 

Congestion occurs in various organs, due to obstruction of the move- 
ment of the blood during a spasm. The brain, cord, lungs and muscles 
are congested. The nerves are often found swollen. 

Symptoms. — The period of incubation is from one to twenty days. 
This is time required for the poison "to be absorbed by the end plates 
in the muscles and to pass up the motor nerves to the spinal cord." In 



378 The Practice of Osteopathy 

most cases the incubation is from five to ten days. A chill precedes other 
symptoms in a few cases. The onset is quite sudden, with stiffness in 
the neck, jaw and tongue. There are headache, stomach disturbance 
and languor. Opening the mouth is difficult, but is not painful. Deg- 
lutition is difficult. The stiffness increases and extends to the spinal 
muscles, abdomen and legs which are held in a firm spasm. Thus, the 
trunk and legs are inflexible. 

These syinptoms vary in degree of severity, dependent upon the 
extent of involvement. The jaws may be firmly locked or they may 
yield to forced extension — "lock-jaw." The muscles of the face may be 
involved, the angle of the mouth drawn out, and the eye-brows raised — 
"risus sardonicus." The neck and trunk muscles affected produce opis- 
thotonos. Spasms of the pharynx and esophagus may occur, especially 
when there are injuries to the fifth nerve. 

Associated with these tonic convulsions is intense pain. The distress 
of the patient is extreme when the chest muscles are affected. All symp- 
toms are increased during the paroxysm. A foot fall, the slamming of a 
door, a draught of air or any slight sensory impression may excite a par- 
oxysm. The paroxysm may relax and during the interval the patient may 
walk about. The spasms vary in frequency from a few minutes to one 
in several hours. During spontaneous or induced sleep the spasm usually 
ceases. The febrile reaction is generally slight and apparently of ner- 
vous origin; in many cases 102 degrees F. In severe cases the tempera- 
ture may be considerably higher. Perspiration is excessive. The urine 
is scanty and high colored. The bowels are usually constipated. The 
mind remains clear throughout. Death is generally caused by exhaus- 
tion. Chronic tetanus presents similar symptoms, but less marked, 
and it develops slowly. 

Diagnosis. — The history of a wound followed by the characteris- 
tic symptoms would rarely occasion an error. Strychnine poisoning 
differs from tetanus in the history, in the more rapid development of the 
symptoms, no trismus at the beginning, marked involvement of the 
extremities, and absence of rigidity between the paroxysms. In tetany 
the extremities are chiefly affected by the spasms, the muscles are relaxed 
during intervals, and trismus is a late or very rare condition. In hydro- 
phobia trismus does not occur and the respiratory spasm is caused by 
attempts at swallowing. The mental symptoms increase. 

Prognosis. — The prognosis is unfavorable. Eighty per cent of 
traumatic and fifty per cent of the idiopathic cases prove fatal. Cases 
that are fatal usually die within six days. Cases where there is slight 



The Peactice of Osteopathy 379 

elevation of temperature, and where the spasm is locaHzed to the muscles 
of the face, neck and jaw, or where muscle stiffness is late in appearing, 
are more likely to recover. 

Treatment. — Free incision and thorough disinfection with hydro- 
gen peroxide and cauterization with pure carbolic acid, of the wound are 
necessary. The patient should be put in a dark room and there remain 
as quietly as possible. Avoid all sources of peripheral irritation. Liquid 
food is to be given, and if the jaws are firmly set, rectal feeding may be 
employed or food may be passed through the nose with a catheter. 

For the spasms, strong inhibition of the nerve centers controlling 
the affected muscles may be of use. Probably the most effectual treat- 
ment for the paroxysms would be strong, thorough treatment of the up- 
per cervical region. Hot baths give relief to the spasms. All the ex- 
cretory organs should be greatly stimulated, particularly the kidneys, 
lungs and bowels. Other symptoms are to be treated as they arise. 
Tetanus antitoxin is highly commended by surgeons who used it dur- 
ing the Great War. As death is at a two to one ratio any method of treat- 
ment is justified. A few cases have been treated osteopathically with 
fair success, following antiseptic measures. 

Simple Continued Fever 

Definition. — An acute, febrile disease, mild in character, of short 
duration, not excited by any special organism and depending on a variety 
of irritating causes. 

Osteopathic Etiology. — The most frequent cause of this form of 
fever is probably gastro-intestinal disturbance. In children it may be 
due to gastro-intestinal derangement, or to the eating of decomposing 
food or to exposure to wet and cold. It may be caused by exposure to 
the sun or great heat, or mental or physical fatigue. It may be the re- 
sult of exposure to cold sufficient to produce a shght bronchitis, tonsillitis 
or other affection producing an unnoticed locaHzed inflammation. It 
may follow a prolonged exposure to noxious odors or gas. Lesions, 
osseous or muscular, are always present, corresponding to the tissues and 
organs disturbed. Muscular lesions, especially, are prominent. 

Symptoms. — The onset is usually sudden with a feehng of lassitude, 
weariness, chilliness, and headache. The temperature rises quickly to 
102 or 103 degrees F. or over, and is usually apt to terminate suddenly by 
crisis on the third or fourth day. The pulse is frequent and the face is 
flushed. The child is often irritable. Mild delirium may occur. An- 
orexia is present, and the bowels arc constipated. Convalescence is rapid. 



380 The Practice of Osteopathy 

Diagnosis. — This depends upon excluding other probable diseases. 
If the fever cannot be attributed to some of the causes already referred 
to, there may be a doubt as to its character for the first twenty-four hours, 
but, if after a careful examination, one finds no other cause and no symp- 
toms develop of any of the recognized diseases, acute continued fever 
can hardly be mistaken for any other disease. 

Prognosis. — Always favorable, recovery without sequelae being 
the rule. 

Treatment. — It is necessary to find out the irritative cause in order 
for one to be able to treat intelligently. Rest in bed with treatment of 
the disturbing factor of the disease, whatever that may be, is the principal 
treatment to be given. Careful examination of all the organs, with due 
consideration of the symptoms, will generally leave no doubt as to the 
cause, and treatment appHed accordingly will be sufficient. If there 
is any gastro-intestinal disorder, thorough treatment of the splanchnics, 
anterior treatment to the abdomen and thorough evacuation of the bowels 
are indicated. Use an enema if necessary. Besides the usual fever 
treatment, sponging the body with tepid water at the time of day when 
the fever is highest will aid in lessening the temperature and render the 
patient more comfortable. In cases where nervous symptoms are prom- 
inent, care should be taken against any excitement and, if insomnia 
results, a quieting treatment in the cervical region is usually sufficient. 
Use plenty of water internally, which is not only necessary for the tis- 
sues on account of the fever, but is of great aid in keeping the skin and 
kidneys active, and thus a great help in the ehmination of waste mater- 
ial. A Hquid, nutritious diet is best. Milk, broths and soups will be 
enough. The demands on the digestive tract are not great when a fight 
diet is administered, besides not exciting the nervous and vascular S5^s- 
tems unduly. 

Tuberculosis 

Definition. — A general or local infectious disease caused by the 
bacillus tuberculosis of Koch. The bacillus produces specific lesions 
of the form of nodular bodies called tubercles that undergo caseous ne- 
crosis with a tendency to involve neighboring tissue. There maj^ be a 
diffusion of the infection by way of the lymph and blood vessels to var- 
ious tissues and organs. 

Osteopathic Etiology and Pathology. — Tuberculosis exists in all 
countries. It generally prevails more extensively in warm than in cold 
cUmates, and is of more frequent occurrence in the city than in the coun- 



The Practice of Osteopathy 381 

try. Altitude, however, exerts more influence than latitude. The dis- 
ease rarely occurs in mountainous countries, owing to the puritj^ of the 
atmosphere. The disease is very prevalent in the West Indies and the 
South Sea Islands. Tuberculosis is frequently met with in Canada 
among the French Canadians and the EngHsh. All races are subject to 
tuberculosis, but the Indians of this continent, the South Sea Islanders 
and the colored race are very susceptible to the disease. It is estimated 
that from seven to ten percent of the present death rate in the United 
States is due to tuberculosis. 

The tubercle bacillus was discovered by Koch in 1881. It is a 
short, straight or sHghtly bent, rod. This bacillus has an exceedingly 
tenacious hold on life and is found in greater or less numbers in all tuber- 
culous lesions. 

It can live almost indefinitely outside the body. The bacilli are 
found in great numbers in the sputum, which dries and flies in the atmos- 
phere in the form of dust. The organism is thus widely spread in regions 
frequented by phthisical patients. The bacillus gains entrance into the 
body by way of the respiratory tract in the vast majority of cases. Milk 
from tuberculous cows wiU produce the disease, especially in children, 
causing intestinal and mesenteric tuberculosis. The meat of tubercu- 
lous animals is not necessarily infectious, although there is a possibility 
of infection by this means. Tuberculosis may be transmitted by direct 
inoculation; this does not often occur in man, but when it does, the dis- 
ease usually remains local, although general infection may occur. Per- 
sons who follow certain occupations, as butchers, dissectors of dead bod- 
ies, and handlers of hides, are more or less subject to local tubercles of 
the skin. The virus may enter the body through any fissure or excoria- 
tion on the skin; thus by Washing the clothes or bed hnen of phthisical 
patients, by the bite of a consumptive, or by a cut from a broken sputum 
glass of a consumptive, one may become infected. It is stated that 
there may be hereditary transmission. In some cases the virus may be 
transmitted and the disease ma3^ not appear for many years. 

Predisposing Causes. — Hereditary predisposition, which renders 
the person more liable to accidental infection ; delicate constitution ; scrof- 
ulous tendency; previous infectious diseases, as influenza, whooping cough, 
measles, typhoid fever; diabetes melhUis, etc. In young children menin- 
geal, mesenteric and lymphatic forms of tuberculosis are the most fre- 
quent. Pulmonary tuberculosis is usually met with in adults, espec- 
ially between twenty and thirty years or age. The development of 
tuberculosis is favored by damp localities; by improper and insufficient 



382 The Practice of Osteopathy- 

food; constant inhalation of impure air; injuries to the chest, with or 
without laceration of the lungs, and various osteopathic lesions that 
weaken the tissue through faulty nutrition. Corresponding to the in- 
nervation of the organ or tissue diseased will always be found anatomical 
derangements. "Every case has a defective spine and thorax." (Hay- 
den'). 

Bronchial catarrh, tonsiUitis, diseases of the stomach and intestines, 
especially enterocoUtis, tubercular pneumonia, pleurisy (rarely), intra- 
thoracic tumors and congenital or acquired contraction of the orifice 
of the pulmonary artery increase the susceptibhHty to infection. Les- 
sened vitality of the tissues, whether inherited or acquired, is necessary 
before the germ can become implanted and proliferate, producing tuber- • 
culosis of the tissues and organs. In nearly every instance, when the 
lungs are involved, lesions are found at the second, tliird, or fourth ribs. 
These lesions undoubtedly predispose to the tubercular infection, by 
lessening the vitahty of the lung tissues through interference with the 
innervation or vascular supplJ^ Possibly a lesion at the second rib or 
second dorsal vertebra would interfere directly with the vasomotor 
nerves of the upper thoracic ganglia. The condition of the middle and 
lower cervical vertebrae should be carefully examined, for lesions at that 
point would involve the lymphatics of the lungs. The lowered vitality 
caused by the lesion is the predisposing cause and the tubercular bacillus 
is the exciting cause which determine the character of the affection. 

C. A. Whiting in Clinical Osteopathy says: 

**The spinal outline characteristic of tuberculosis and of the pre- 
tubercular stages presents the following peculiarities : The cervical spine 
presents various abnormalities, usually lesions involving single vertebrae 
and associated with irregular muscular tensions. The upper thoracic 
spine is anterior, the ribs drooping and rather more freely movable than 
normal; the vertebral articulations are less movable than normal; the 
tissues in the neighborhood of the upper two or three dorsal spines are 
abnormally sensitive and the muscles innervated from these segments 
are contracted irregularly when the disease involves the apices. The 
lower interscapular region is found sensitive and these muscles are con- 
tracted when the lower lobes of the lung are involved, and the location 
of these sensitive areas may be employed in the locahzation of the lung 
area infected. 

"In every case recorded in this clinic, lesions involving the area 
of the origin of the upper and middle splanchnic nerves have been 
1. Journal of the American Osteopathic Association, March 1906. 



The Practice of Osteopathy 383 

found. The typical tuberculosis spine must include lesions of the lower 
dorsal area. Probably these lesions are predisposing factors in tubercu- 
losis, partly because of the effects produced upon nutrition thereby, but 
doubtless the lack of the normal mobility of this part of the spine pre- 
vents the normal stimulation of the liver, the spleen, perhaps the pancreas, 
thus the normal opsonic index is lost, and immunity broken. The treat- 
ment of tubercular cases should include careful attention to the splanch- 
nic area, the maintenance of the normal mobihty and structural rela- 
tionship of the entire spinal column, and such stimulating movements to 
the ninth and tenth thoracic neighborhood as is indicated in each indi- 
vidual case. " 

Pathology. — In adults the most common site of tubercles is the 
lungs; in children it is the lymphatic glands, joints and bones. No 
organ is exempt ; the saKvary glands and pancreas are the least frequently 
involved. The mihtary tubercle is the beginning of tubercular deposits. 
This may develop in any tissue where the tubercle bacillus is found and 
it is only distinguished by the presence of a tubercle bacillus, as similar 
conditions are produced by the aspergillus glaucus and actinomyces. 

In the development of a tubercle there is proHferation of the fixed 
tissue cells, particularly those of the connective tissue and the endothe- 
lium of the capillaries, due to the irritation of the bacillus, producing the 
epithelioid cells and in some instances the giant cells, in both of which ba- 
cilli may be found. The epithehoid cells vary in shape. The giant cells 
are formed by enlargements of the epithelioid cells and a repeated divis- 
ion of their nuclei or possibly by fusion of several cells. On account of 
the inflammation produced by the bacillus, there is migration of leuco- 
cytes from the adjacent vessels and lymphoid cells. The leucocytes are 
largely polynuclear and are rapidly destroyed, but later mononuclear 
leucocytes appear, which are able to resist the action of the bacilli so that 
they are not so readily destroyed. A reticulum of connective tissue 
is formed around the various cells. The tubercles are non-vascular and 
when once formed undergo caseation and sclerosis. 

Caseation is a process of coagulation necrosis or destructive change, 
beginning at the central part of the growth, due to the action of the 
bacilli. The primarily transparent tubercular tissue may become a gray 
gelatinous body containing bacilU. Frequently the caseation is followed 
by softening; less frequently, calcification, or it may be surrounded by 
fibrous tissue. 

During the time the cell destruction is going on at the center of the 
tuliorele, hyaline and fibrous changes may render the tissues sclerotic. 



384 The Practice of Osteopathy 

These changes, caseation, the destruction of forces, which are danger- 
ous to the patient, or sclerosis, which is a healing process, depend upon 
the power of the body to produce an antitoxin to overcome the effects of 
the special toxin produced by the bacilh. 

There may be a widespread tuberculous involvement. This 
is the result of fusion of the new foci of infection or of mihary tubercles. 
The lungs are the usual site of infection, varying from a small area, to a 
lobe or a still greater area. 

The irritation of the bacilli is capable of producing associated 
inflammatory processes in its own neighborhood. There may be an 
overgrowth of interstitial tissue. In other instances, changes to catar- 
rhal or croupous pneumonia may occur. Suppuration is associated 
with tuberculosis, especially of the lungs, and is due to a mixed infection 
or the presence of pus organisms. Some authorities claim that the tu- 
bercle bacilli alone are able to produce suppuration; it is, however, more 
probable that suppuration is due to a mixed infection. The constitu- 
tional features in tuberculosis are more dependent upon this secondary 
infection, especially by the streptococci, than upon the primary infection. 

Tuberculosis of the Lymph Glands 

(Scrofula) 

Scrofula is a true tuberculosis of the lymphatic glands. The virus 
is less virulent than that from other sources, which accounts for the slow 
development and milder course of tuberculosis of the glandular system. 

Tuberculous Adenitis may occur at all ages, but is most common 
in children and young adults. It is rarely congenital. Catarrhal in- 
flammation of the mucous tissues weakens the resisting power of the 
lymph tissue, thus allowing the bacilh to develop, and is an important 
predisposing cause. The glands most frequently affected are those of 
the neck; more rarely there is involvement of all the lymphatic glands 
of the body. Invariably lesions of the upper and middle cervical verte- 
brae and upper dorsals and corresponding ribs are found, as well as le- 
sions to the lymphatics at various points along the spinal column and 
ribs. These lesions affect the innervation to the lymph glands, as well 
as mucous membranes, and thus predispose to the disease. In all cases 
anatomical derangements are found in the region of the innervation to 
the involved gland. 

In general tuberculous adenitis all the lymph glands of the 
body are more or less involved, while the other organs and tissues are 



The Practice of Osteopathy 385 

rarely affected. All the visible glands are found to be swollen, tender 
and painful. There is more or less protracted fever, with wasting and 
debility. This is a rare affection. 

In local adenitis the glands of the neck are most frequently affect- 
ed and this is especially the case with children. Negroes are more fre- 
quently affected than whites. It is seen especially among those living 
in an unsanitary environment. Measles, whooping cough and an hered- 
itary tendency are predisposing factors. The submaxillary glands are 
usually the first affected. At first they are swollen to various degrees 
and are tender; later they suppurate and rupture if one is not able to cure 
them. There may be fever. The skin over the glands is usually freely 
movable; it may, however, be adherent. 

The glands above the clavicle, those in the posterior cervical tri- 
angle, and the axillary glands may all be affected. In such cases it is likely 
that the bronchial glands are also involved and may infect the Hving tis- 
sue. 

Lesions of the upper and middle cervicals and deep muscles are al- 
ways found and undoubtedly are the underlying causes. Lesions of 
the lower cervical, upper dorsal, ribs and clavicle, are of frequent occur- 
rence. Infection may gain entrance by way of the pharynx and tonsils. 

The affection often runs a slow course. 

The bronchial glands may be affected primarily, but usually second- 
arily to infection of the lungs. The primary form is seen most common- 
ly in children and is apt to be associated with suppuration. Lesions of 
the upper and middle dorsals and of the cervicals will be found. Catarrh 
of the bronchial tubes is a predisposing cause. The X-ray is of great 
value in the diagnosis . ■ 

The most noticeable symptoms are those due to pressure or irri- 
tation. 

Systemic infection may follow rupture into a vessel. Local infection 
of the lung may occur and the pericardium become infected. 

Mesenteric cases occur among children and may be primary or 
secondary. The primary form is rare. Swallowed sputum is a frequent 
cause. The trunk and hmbs are puny. The child is anemic, and often 
the abdomen is tympanitic. Diarrhea is marked and there is pain and 
indigestion. Fever is almost constantly present and of an intermittent 
type. The disease is most frequently met with among poor children 
in unhygienic, poorly ventilated houses. There may be an associated 
tuberculosis of the peritoneum. 



386 The Practice of Osteopathy 



Acute Tuberculosis 



This shows best the truly infectious nature of tuberculosis. In 
it mihary tubercles develop in many and various parts of the body. In 
some cases these growths seem to be uniformly distiibuted throughout 
all the viscera. In other instances they are locahzed in the lungs or 
in the meninges of the brain. In nearly every instance it is an auto- 
infection, arising from an old tuberculous focus, which may be latent and 
quite unsuspected. General infection, in most instances, arises from the 
rupture of a nodule into a vein, from tuberculous lymph glands, tuber- 
culosis of the bones, joints, or even the skin. 

General Miliary Tuberculosis or Typhoid Form. — This is sim- 
ilar to a general infection of the body and resembles, to a marked degree, 
the symptoms of typhoid fever. The onset is rarely rapid. 

In most cases there is a period of incubation, during which the health 
fails, the appetite is lost, headache occurs, and the patient soon becomes 
feverish, with increased debility. The temperature rises and the pulse 
is rapid and feeble. The tongue is dry. The respirations are increased. 
Dehrium may be present. In rare cases, there may be Uttle or no fever. 
The temperature ranges from 101 to 103 or even 105 degrees F. It is ir- 
regular and marked by evening exacerbations and morning remissions. 
Occasionally there is an inverse type of temperature in which it rises in 
the morning and falls in the evening. In some cases the pulmonarj^ symp- 
toms are marked, while in others the meningeal symptoms are more prom- 
inent. Tubercle bacilH are rarely found in the sputum. 

The spleen is usually enlarged. Constipation is present, as a rule, 
but there may be diarrhea, and hemorrhage from the bowels may occur. 
The ui'ine may contain traces of albumin. There may be excessive sweat- 
ing, and herpes is often present. Choroid tuberculosis is frequently met 
with. In doubtful cases the blood should be examined for tubercle 
bacilli, although they are not always present. The duration is from two 
to four weeks, the disease usually terminating unfavorabty. 

Diagnosis. — It is often very hard to differentiate between this form 
of tuberculosis and typhoid fever. In typhoid fever epistaxis is a common, 
early symptom. The temperature curve of the continued type is quite 
diagnostic. The Widal test should be made. The respirations are mod- 
erately hurried and the pulse is often dicrotic. Diarrhea is frequent. 
Typhoid rash is diagnostic. No tubercles are found on the choroid. 
No tubercle bacilli are found in the blood. Hemorrhages from the bowels 
are common. 



The Practice of Osteopathy 387 

Pulmonary Form. — When the lungs are chiefly affected the pul- 
monary symptoms are marked from the onset. It may develop sud- 
denly or there may be a long period during which the general health 
fails markedly. In children the disease may follow measles or whoop- 
ing cough. There is dyspnea, cough and the expectoration is muco- 
purulent. There is broncho-vesicular breathing with sibilant and sub- 
crepitant rales. The temperature is high, ranging from 103 to 105 de- 
grees F., or higher. Respiration and pulse are rapid. 

The disease may last from several weeks to months, or, on the other 
hand, it may prove fatal within a few days. As the end draws near the 
signs of suffocation become intensified. 

Diagnosis. — The history and general symptoms, together with the 
dyspnea and cyanosis, will generally decide the diagnosis. The blood 
should be examined for malarial parasites. The Widal test will differ- 
entiate typhoid. 

Cerebral or Meningeal (Tuberculous Meningitis). — This form 
which is sometimes called acute hydrocephalus, occurs quite frequently 
and is an infection of the pia mater of the brain or cord. 

It occurs most frequently in the first two years of life, although it 
may occur later. It is usually tuberculous in some other region, especial- 
ly in the bronchial glands. Rarely does the disease involve the menin- 
ges primarily. 

The meninges at the base of the cerebrum is the principal involve- 
ment. There is more or less inflammation, with fibrous purulent exuda- 
tion. There are tubercles along the blood vessels. The ventricles may 
be distended. 

Symptoms. — The onset is slow, lasting one or more weeks. Head- 
ache, constipation, vomiting and chills, followed by a fever, are the ini- 
tial symptoms. When the onset is sudden, the disease is generally usher- 
ed in with a convulsion. The fever rarely rises above 102 or 103 degrees 
F. The pain is often severe, causing the child to give a sudden cry — 
the hydrocephahc cry. During sleep the child is restless and there are 
slight muscular twitchings. 

The irritative symptoms now abate. The child becomes quiet 
and is dull and apathetic. Constipation still persists. The abdomen is 
boat-shaped, and the neck may be retracted. The pupils are dilated. 
Convulsions and other cerebral symptoms may occur. The tempera- 
ture ranges from 100 to 103 degrees F. The respiration is irregular and 
sighing. 

Following this, tlie mental faculties are lost and coma occurs. Con- 



388 The Practice of Osteopathy 

vulsions or spasmodic contractions of the muscles of the neck, back and 
limbs may occur. The pupils are dilated and do not respond to light. 
The pulse is frequent, irregular and small. The temperature rises to 103 
to 105 degrees F., or it may be subnormal. The duration is from two to 
five weeks; chronic cases may last for a number of months. 
Prognosis. — Generally very unfavorable. 

Acute Pneumonic Phthisis 

The infection of the lungs is rapid and may be primary or secondary. 
This form is met with most frequently in children and young adults, 
but may occur at any age. 

The Pneumonic form is more rare than the bronchopneumonic 
form and may be very rapid in its course. The attack sets in abruptly 
with a chill and the temperature rises rapidly. There is pain in the side ; 
cough; dyspnea and mucous and rusty sputum, which may contain tuber- 
cle bacilli. There is impairment of resonance, increased fremitus, and 
bronchial breathing. The whole or part of the lung may show signs 
of consolidation and dullness, all the symptoms of pneumonia being 
present. The patient rapidly loses flesh. This attack may come on a 
person in good health after exposure to cold ; but there may have been a 
debihtated condition, or a predisposition to phthisis. Death may occur 
in the second or third week or the case may continue from three to four 
months. 

One or both lungs may be involved. The lung is heavy and airless, 
sinking quickly in water. There is destruction of lung tissue and upon 
section, cavities are found. The cavities are generally small and are sur- 
rounded by tubercles. Older caseous areas of a yellowish white color 
may be visible. Miharj^ tubercles are found upon careful examination. 

The bronchopneumonic form is the most common and occurs 
most frequently in children. It often follows the infectious diseases, 
especially measles and whooping cough. The child may be taken ill 
suddenly with what seems to be an ordinary bronchitis, the temperature 
rises, the cough is severe, and there may be consolidation with submu- 
cous and sub crepitant rales. Rapid respiration and sweating are often 
marked. The course of the disease varies. There is rapid loss of flesh, 
and in many cases the disease develops into chronic phthisis. In other 
instances death occurs in from three to eight weeks. 

The disease may attack the adult whose resistance is impaired. 

Chills, fever, pain in the chest, hemorrhages, wasting are most noticeable 

ms; these are the various signs of bronchopneumonia. Tubercle 



The Practice of Osteopathy 389 

bacilli are often found in the sputum. The course is usually from three 
to eight weeks, while a number pass into a chronic stage. 

Areas of caseous tubercles are found, which later suppurate, break 
down and form cavities. The bronchial lymph nodes are found enlarged, 
and usually there is acute tuberculous pleurisy. 

Diagnosis. — In the pneumonic form it may be impossible to 
make a diagnosis early in the disease. Tuberculosis may be suspected 
if the patient has been in bad health, has a predisposition to phthisis, or 
has had any pulmonary disorder. Pneumonia will present the typical 
symptoms, but if fever continues, tuberculosis will be suspected. Ex- 
amination of the sputum will probably decide. 

In the bronchopneumonic form it is very difficult, in the early 
stages, to distinguish it from simple bronchitis and bronchopneumonia. 
The irregular fever and rapid loss of flesh are important signs. The 
sputum will show elastic tissue and tubercle bacilh early in the disease 
and should be carefully examined. 

Chronic Pulmonary Tuberculosis 

The chronic form of the disease is more common than the acute. 
It seems probable that many cases of pulmonary tuberculosis are due to 
inhalation of the tubercle bacillus, though no doubt, particularly in chil- 
dren the bacillus frequently gains entrance to the system through the in- 
testinal tract from infected milk and food. Deformities of the chest, 
especially where there is constriction and rigidness of the upper part, 
with more or less immobility of the first, second and third ribs and the 
junction of the manubrium and gladiolus, associated with weak muscles 
and a stooped posture are definite predisposing factors. This condition 
may be congenital or acquired. The local innervation, blood supply and 
lymphatic drainage is involved, so that the individual is less resistant and 
consequently susceptible to infection. The bronchi are thus weakened, 
favoring the infectious process so that the disease may advance and in- 
volve the neighboring tissues, or if infection has gained entrance to the 
lymph or blood stream elsewhere, the susceptible pulmonary organs may 
become diseased. 

Owing to the above predisposing factors the primary lesion of the 
lungs is often in the bronchus a little below the apex near to the posterior 
and external borders. A lower lobe may be involved, or several lesions 
may occur at the same time, involving one or both lungs. Frequently 
the other lung is infected from the lesion or lesions of the first. 

In the acute cases the exudative process involves the lung tissue, 



390 The Practice of Osteopathy 

becomes caseous and softened, and later necrotic with cavity formation. 
In the chronic type the exudative process is slower, with thickening of 
the walls of the air vesicles and increase of fibrous tissue. Cavities, the 
result of caseation, are of various size, ragged, often coalesce and open in- 
to the bronchus. Fibrous tissue forms about them and frequently arrest 
the process. In the necrotic involvement blood vessels are often injured 
causing hemorrhages. Pleurisy, empyema, catarrhal bronchitis, and 
bronchiectasis are often associated involvements. 

In addition to the tubercle bacillus, other microorganisms, strepto- 
coccus and staphylococcus pyogenes, influenza bacillus, and diplococcus 
pneumoniae, are often found, and no doubt are important exciting factors. 

The bronchial glands are swollen, and contain tubercles. They 
may undergo purulent disintegration. Tuberculosis of the larynx 
is common. In. severe cases there may be amyloid changes of liver, 
iiidneys, spleen, and mucous membrane of the intestines. Tubercu- 
lous lesions are found in the intestines, spleen, kidnej^s, and brain in near- 
h' equal proportions; then come the liver and pericardium. 

Symptoms. — The onset of the disease is either abrupt or gradual. 
Frequent!}' it succeeds influenza, measles, or bronchitis. There is a 
cough, expectoration, loss of weight, afternoon temperature and probably 
night sweats. The disease is hkely to develop slowly. In other cases 
gastro-intestinal disorders are the first symptoms, especially with weak- 
ness and debihty. Again, the disease may follow pleurisy. When the 
attack is abrupt, pneumonia is simulated. However, the apex of the 
lung, instead of the middle or lower lobe, is involved; expectoration is 
considerable and the fever is not so high and pronounced. Hemoptysis 
frequently occurs. 

The local symptoms are important. Pain is an early either mod- 
erate or severe, sjniiptom, although there are cases where it is absent. 
When associated with pleurisy, it is severe. The pain is usually situated 
at the base, anteriorly or laterally, of the scapulae, but may be between 
them. Cough is present, in the majority of cases, throughout the entire 
course. It usually grows worse, and is dry and hacking at the beginning 
but looser and paroxysmal and accompanied by a mucopurulent expecto- 
ration later on. The expectoration, at first, is slight and there may be 
more or less blood mixed with it, or even hemorrhage may occur. With 
the formation of cavities, the expectoration increases and is of a greenish- 
gray or greenish-yellow color. In some instance the sputum is more or 
less fetid. The expectoration is composed of pus cells, blood, elastic 
tissue, fat glol^ulcs and tubercle bacilli. Hemoptysis is present in a 



The Peactice of Osteopathy 391 

majority of cases. Early hemorrhages are usually sMght, due to rupture 
of weakened vessels. When there is softening or cavity formation, ero- 
sion of vessels may be pronounced and hemorrhage considerable. Dysp- 
nea is a variable symptom, but is characteristic of lung changes. 

Fever is a characteristic symptom. It is probably always present 
at the beginning and the afternoon increase of temperature is common. 
Where there is softening and formation of cavities, a remittent or inter- 
mittent type is present. The pulse is frequent, regular and compressible. 
Sweats may occur at any time, but especially during sleep. They in- 
dicate fever activity, and are increased during cavity formation. Ema- 
ciation is a prominent symptom. This is due to gastro-intestinal dis- 
orders and prolonged fever. Loss of weight is gradual, especially if the 
disease is advancing. Where the lung is considerably diseased, heart 
disturbances are comm.on. 

Other disorders, as of the gastro-intestinal tract, genito-urinary, 
cutaneous, and nervous sj^stems, are frequent, especially in long stand- 
ing cases. The gastro-intestinal disturbances are gastric catarrh, 
vomiting, loss of appetite, coated tongue, constipation, and later on, 
diarrhea. Among genito-urinary symptoms, albuminuria is frequent. 
The kidney involvement may be either of an acute or chronic character. 
Pyehtis and cystitis are present in some cases, and amyloid degenerations 
are not uncommon. With the cutaneous symptoms, the skin is fre- 
quently dry and scaly, and the hair of the head dry. The hectic flush 
is common. Upon the chest and back there may be pigmentary stains. 
The nervous symptoms vary according to the involvement. Tuber- 
culous meningitis is rare. The mind usually is clear and even in advanced 
stages the patient is always hopeful. 

Physical Signs. — Inspection reveals that the shape of the chest 
is often characteristic. A phthisical thorax is flat, especially the thoracic 
opening with wide intercostal spaces, prominent costal cartilages, and 
depressed sternum. Sometimes the lower sternum forms a deep concav- 
it}^ (funnel breast). Another type of thorax is long and narrow, with 
very oblique ribs, and Httle expansion. In other instances the chest is 
of apparently normal build. Defective expansion is observed early, es- 
pecially at the apex of the affected side. The clavicle of the ajffected 
side often stands out more prominently. 

Palpation shows there is decreased expansion and increased frem- 
itus. Normally, the fremitus is stronger at the right than at the left 
apex. If the pleura is thickened, the fremitus is decreased, l^ut increased 
in lung involvement. 



392 The Practice of Osteopathy 

On percussion, if the diseased areas are minute, the percussion 
note may not be changed. Always compare the two sides of the chest. 
Dulhiess is first noted, as a rule, above, on or below the clavicle. As 
the disease progresses, the dull sound increases. The size of the cavitj' , 
its walls and the amount of secretion modify the note. Large, thin- 
walled cavities elicit the "cracked-pot" sound. Consolidation, thicken- 
ed pleura, large amount of material in a cavity and a connecting bron- 
chus impair resonance. 

On auscultation the breathing is harsh and the expiration is pro- 
longed and high-pitched (bronchial). Early in the disease crackling rales 
may be heard. After consoUdation takes place there is bronchial breath- 
ing and crepitant rales. When softening occurs they become moist, loud- 
er and sometimes bubbling. These may be heard upon inspiration and 
expiration. Pleuritic friction sounds, as in case of pleurisy, may be heard 
at any stage. Vocal resonance is increased. 

The signs of cavity are: Percussion. — There is more or less de- 
fective resonance or tympany. Over large cavities a "cracked-pot" 
resonance is obtained. This is best obtained when the patient has his 
mouth open. There may be normal resonance if the cavities are covered 
with a considerable thickness of unaffected air cells. 

Ausculation may detect cavernous or amphoric breathing, pec- 
toriloquy and coarse, bubbling rales. Metallic tinkling may be heard 
over large cavities. Vocal resonance is increased. 

Complications. — The larynx and trachea frequently undergo tu- 
bercular inflammation, due to invasion from the lung tissue. Pneumonia 
is of common occurrence. Gangrene, pleurisy and endocarditis are other 
complications. 

Diagnosis. — Bacilli may be found in the sputum before the physical 
signs are well developed. It may be necessary to examine the sputum 
several times before the tubercle baciUi are detected. The presence of 
bacilli will set the diagnosis at rest, provided clinical symptoms are pres- 
ent. Fever, hemoptysis, cough, emaciation and a continuous, local 
induration arc diagnostic. The X-ray should be employed as an aid in 
diagnosis. 

Prognosis. — The prognosis of pulmonary tuberculosis varies greatly 
in different cases. Undoubtedly a number of cases have been cured; 
many arrested; even spontaneous cures have occurred. A great deal can 
be done to prolong life and to make the patient comfortable. The aver- 
age duration is about three years, although by careful treatment this 
time is probably being increased. 



The Practice of Osteopathy 393 



Fibroid Phthisis 



This term is applied to a form in which there is induration, followed 
by contraction of the affected lung tissue, due to an overgrowth of fibroid 
tissue. The greater number of cases are primarilj^ tubercular, but have 
run a fibroid course. Other cases are primarily fibroid, followed by tuber- 
culous infections. It may begin as an ordinary ulcerative phthisis, or 
it may begin as an inhalation bronchitis. In other instances it may fol- 
low a chronic tuberculous bronchial pneumonia or pleurisj^ 

The onset is extremely insidious. There is persistent cough, often 
paroxysmal in character. Dyspnea is marked, especially on exertion, 
but little or no fever is present. The expectoration is profuse and muco- 
purulent. There is slight loss of weight. In the later stages edema is 
marked. It is a disease of long duration, lasting from ten to twenty years. 
The patient is often able to pursue some occupation and may have fair 
health. 

There is marked dullness over the affected side, which is commonly 
much depressed. There is distinct bronchial breathing at the base, while 
at the apex there may be cavernous sounds. The heart is frequently dis- 
placed and the right ventricle hypertrophied. The bronchi are dilated. 
The chnical history is identical with that of simple cirrhosis of the lung 
from which it is often separated with difficulty. Both lungs may become 
the seat of tuberculous disease. Prolonged suppuration results in amyl- 
oid changes in the Hver, spleen, kidneys and intestines. X-ray plates 
are of value in diagnosis. 

Tuberculosis of Other Tissues 

The alimentary tract is frequently the seat of tubercular inflam- 
mation. The intestines may be involved primarily or else secondarily 
from the lungs or peritoneum. The primary form is most common in 
children. There is slight fever, pains of a colicky nature, irregular and 
persistent diarrhea. The disorder is commonly unrecognized, being mis- 
taken for appendicitis or other intestinal disorders, until emaciation, 
sweats, the continued fever or lung involvement are manifested. 

The stomach, esophagus, pharynx, tonsils, palate, tongue and lips 
may be the seat of a tubercular lesion. 

The serous membranes are usually secondarily involved. The 
peritoneum is generally invaded from contiguous organs, especially the 
intestines, although the pleurae may be the starting point (and in the 
female the generative tract is a source) . The disease may be either acute 
or chronic. In the former it starts abruptly with vomiting, pain in the 



394 The Practice of Osteopathy 

abdomen, fever, and possibly diarrhea. In the chronic form there are 
fever, pains, emaciation, weakness and the abdomen is distended. The 
enlarged glands may be felt through the walls. There may be ascites, 
or the walls of the peritoneum are adherent, or the tubercles may ulcerate. 

The endocardium is occasionally the seat of acute or chronic tubercu- 
losis. It is usually secondary. Likewise the pleurae are sometimes in- 
volved. The chronic form is more common. 

The genito-urinary system is subject to tuberculosis. The blad- 
der, ureters and pelvis of the kidney are attacked, and from these the 
kidney; or possibly the kidney involvement is part of a general tubercu- 
losis. (See pyeUtis). The ovaries, Fallopian tubes and uterus are also 
subject to tubercular invasion. The diagnosis depends upon finding 
the bacilH, the symptoms indicating, oftentimes, an inflammation only. 
Also the prostate, testicles and seminal vesicles are attacked. 

Tuberculosis of the mammary glands is rare. In miliary tubercu- 
losis the liver is commonly affected, often secondary to other tissues, es- 
pecially the peritoneum, lymphatics and lungs. 

The blood-vessels and heart are sometimes involved from nearby 
organs or from miliary tuberculosis. The brain and cord are also at times 
invaded. This has been described under meningeal tuberculosis. 

Diagnosis and Prognosis of Tuberculosis. — The osteopath .should 
be familiar with the various forms of the disease. An understanding of 
the pathology and chnical symptoms is essential. The finding of the 
l^acillus, provided there are symptoms of inflammation, is diagnostic. 
Much depends upon the patient's constitution, hygiene, sanitation, food, 
fresh air and general management. The osteopathic lesion is decidedly 
an important factor, but the treatment must be balanced from both 
the distinctive osteopathic view and that of general management. Then 
the patient's part is as necessary as the osteopath's. Under proper care 
and treatment, unless the disease has progressed to a marked degree, there 
is always a tendency toward recovery, but, to emphasize again, the os- 
teopathic treatment, the environment and general hj^giene should be 
thoroughly understood and appreciated, for at best, the disease is treach- 
erous. Even after an apparent recovery is made, the patient should be 
under observation; there is always danger of recurrence. Tuberculosis 
can '■often be treated successful!}^, or arrested, provided the disease has not 
progressed to a late stage; although many times, in the later stages, hfe 
can be considerably prolonged by careful treatment. 

Treatment of Tuberculosis. — The prophylactic treatment 
of tuberculosis should receive first consideration. The sputum should 



The Practice of Osteopathy 395 

be thoroughly disinfected and care taken that the patient does not spit 
about carelesslj^ A spit-cup should be provided and the sputum collect- 
ed and destroyed by burning and the cup steriHzed. The patient should 
be well taken care of and given a separate apartment, so that the danger 
of conveying the disease to others is reduced to a minimum. He should 
occupy a single bed. All unnecessary furnishings of the room should 
be removed and the objects that remain in the room should be frequently 
aired and disinfected. The general and sanitary environment of the 
patient should be as favorable as possible to hygienic living. Many 
times a change of residence is of great benefit. When possible the patient 
should be out of doors and light exercise taken. The body should be well 
protected by flannels, the year around. 

Keene^ would carry prophylaxis to careful examination of the preg- 
nant woman to avert a sudden development of tuberculosis after par- 
turition; also of the child, after birth, to remove any predisposing lesions. 
The mother with a tubercular tendency should, under no circumstance, 
nurse the child and should be instructed to observe any disposition on the 
part of the child to acquire malpositions in sitting, standing or walking. 
Another important consideration in the prophylactic treatment 
is the inspection of dairies and slaughter houses. The disease may be 
transmitted by infected milk. There is less danger of infection through 
meat; although all animals that present distinct lesions should be con- 
fiscated. Sanatoria and other special arrangements for the care of pa- 
tients should be encouraged. 

The Treatment of the disease consists primarilj^ in locating the 
cause of the devitalized condition of the cellular tissue. This is the 
vital point to be considered and requires a thorough examination of 
anatomical structures in the region involved. There is a reason why the 
tissues are in a depraved state and it is our work to examine thoroughly 
the structures that might become deranged anatomically and cause an 
obstructed innervation or vascular supply. The disease is not primarily 
due to the bacilli; the bacilli would not have infected the system had it 
been in a healthy state. Hence, the object of the treatment in tubercu- 
losis is to favor a building up of normal, well-nourished tissues so that it 
is impossible for the bacilH to infect the region. Of course, destruction 
of the bacilli is important, but we cannot expect to do much by the use 
of a parasiticide, for we are not then influencing or affecting the real cause 
of the disease. If we can improve the arterial circulation to the diseased 
tissues, we will be striking at the root of the disease and the healthy blood 
1. Journal American Osteopathic Association, December 1904. 



396 The Practice of Osteopathy 

will be the only parasiticide necessary. This is where the osteopathic 
theory of the cause of disease differs from that of other schools of medi- 
cine. At the local points of infection there is a decided malnutrition of 
the tissues, due to a lack of proper blood to the parts, thus favoring the 
lodging of micro-organisms; by re-estabhshing normal nutrition nature 
will repair the tissues if the condition is curable. Hence, it can be seen 
at once that if the case is curable osteopathic treatment will meet the 
demands scientifically. 

The preceding is the key-note of osteopathic therapeutics; not only 
in the treatment of tuberculosis, hut in all diseases where micro-organisms 
play an important part. In tuberculosis of any part of the body, 
it is the duty of the osteopath to carefully examine the structures that 
may become anatomically deranged, from any cause, affecting the nerve, 
blood and lymphatic supply to the tissues or organs diseased. Cor- 
rection of anatomically deranged tissues and attention to the hygiene, 
diet and general health of the patient constitute the treatment. 

On the subject of Pulmonarj^ Tuberculosis, W. Banks Meacham says: 

"In cases of pulmonary tuberculosis it should be remembered 
that the pathological lesion in the lung is a result of a general systemic 
interference — an interference so great that the body as a whole loses 
its stored-up heat in excessive temperature, loses its reserve nutrition, 
as manifested by early and continuous loss of weight. 

"Therefore the causative osteopathic lesion should not be sought 
alone over the site of the pathological lung lesion but rather in that area 
where general nutrition is osteopathically affected. 

"A few general considerations of osteopathic mechanics involved 
in nutrition should be ever present with the searcher for the cause of 
pulmonary tuberculosis. For instance we know that ingested fat is 
acted upon by the pancreatic enzymes; that the invertin of the intestine 
is an endocrine secretion. In diet we seek to administer an excess of 
fats to take the place of fat-loss in this disease, often losing sight of the 
fact that some mechanical maladjustment prevents fat-spUtting into a 
form suitable for tissue assimilation. 

"It is common osteopathic knowledge that lesions of the upper 
dorsal area have a profound influence on general nutrition. Consequent- 
ly it is to this area that we must look for the causative osteopathic les- 
ion in this disease. The influence of thiss area is due to the fact that the 
nervous mechanism of the secretory glands gets its most direct disturb- 
ance in this area where the nerves leave the spinal cord to become 
distinct innervation to these organs. 



The Practice of Osteopathy 397 

"Apart from the nutritive and general circulatory influence of upper 
dorsal lesions we must consider the germicidal action of the endocrinous 
secretions in devitalizing the specific bacterial agent in tuberculosis. 
Undoubtedly these internal secretions have marked effect in agglutinat- 
ing the bacilH, thus enabling the phagocytes to perform a larger duty. 

"The correction of upper dorsal lesions, with due regard for the 
pathological condition within the thoracic cavity gives a scientific physio- 
logical and bacteriological therapeutic action in tuberculosis. 

**Other lesions may and do demand attention and correction when 
possible. But we must not lose sight of the fact that our specific action 
comes from a corrected relation of the upper dorsals. In the cloud of 
unproved theories and guesses in the Kterature of pulmonary tubercu- 
losis nothing seems nearer an established truth than that it is a disease 
contracted in infancy, that it develops, later, in those persons who retain 
the infantile type of chest — thorax of large antero-posterior diameter 
in contrast with the lateral diameter. 

"In the progress of the disease we do get a costal malformation 
giving the 'horse-collar' thorax, with an apparent lesion of the os- 
seous walls of the thoracic cavity. But these lesions are the result of 
nutritive changes brought on by the active infection already present; 
and are not in any true sense, causative factors in the estabhshment of 
pathological areas within the lung. 

"The osteopathic treatment, then, of this disease is, manifestly, 
a correction of a plastic posterior upper dorsal lesion. And where the 
pathological lesion of the lung contraindicates forceful correction, mo- 
bihty of the area should be sought. 

"The general care of the case should look to the normal func- 
tioning of all organs, with emphasis on ease to the patient. The diet 
should be what the patient can assimilate properly even though it be 
much less than the amount a normally active person should ingest. Al- 
titude has a favorable effect in selected cases only. It is remarkable 
that many cases recover in the extremes of the Rockies and the coasts 
of California and Florida. 

"No violent exercise should be undertaken on account of the possi- 
ble embarrassment of an already overworked heart and in considera- 
tion of the possibly engorged pulmonary vessels. For these reasons, 
too, rest in bed is advisable with temperature above 99° F. and pulse 
above 85." 

In scrofula, lesions will be found to the lymphatic glands, impair- 
ing their innervation and function. The treatment is not to be applied 



398 The Practice of Osteopathy 

over the glands directly. First, it is necessary to locate the lesions of 
the bones, hgaments and muscles or such tissues that would cause dis- 
turbances to the glands, then readjust the parts. The object of the 
treatment is to modify the soil conditions on which the bacilU multiplj', 
by correcting the local derangement of the tissues. The entire body 
is not in such a depraved state that the bacilH will grow and multiply 
wherever they happen to come in contact with the body; tissues of any 
organ favor a receptivity for the bacillus only when these local tissues 
are in a morbid condition. It is then our work to aid nature in relieving 
obstructed forces that are causing such an effect. 

There are general measures which influence the tuberculai- pro- 
cess. The diet of the patient should be nutritious. A diet of milk, 
l^uttermilk, egg albumen and meat juice will probably be found best, 
although many -will be able to take ordinary food. The patient should 
be out of doors as much as possible. Meacham^ says "Fresh, pure air, 
wherever found, is essential; elevation is an individual requirement, an 
even temperature is not necessary and sunshine is important only as it 
allows the patient to be out of doors. Exercise should not be taken when 
the patient has a temperature above 99 degrees." The dry, even cli- 
mate of the Southwest certainly tempts the patient to be out of doors 
more than one with opposite conditions. Even when the patient is 
greatly debihtated and weakened, insist upon his taking outdoor exer- 
cises or rides. Gymnastic and methodical breatliing exercises are essen- 
tial in widening and strengthening the chest. Bolles" believes that the 
appetite should control the diet and forced feeding be not insisted upon. 
Fasting, to test the sense of food desires, has points well worth looking 
into, as gastric disturbances with a loss of strength follow over-feeding. 
He also recommends deep breathing and physical culture to elevate the 
ribs and increase thoracic expansion. Outdoor sanatoria are being es- 
tablished over the country, in many cases by state appropriation as, 
"the treatment of tuberculosis itself has not been a satisfactory proced- 
ure except by climatic changes or the outdoor treatment persistently 
applied." (Halbert). The fresh air treatment may be taken at home 
by sleeping in the open air or by apphances fitted to the window of the 
room so only the head is exposed to the air. The only factor is to get 
the air. The skin, as well as the excretory organs, should be kept active. 
Always make it as comfortable for the patient as possible. 

The fever is indicative of the activity of the disease, so that treat- 

1. .Journal American Osteopathic Association, May, 1905. 

2. Journal American Osteopathic Association, May, 190.5. 



The Practice of Osteopathy 399 

ment to influence the process and to promote elimination is best. Spong- 
ing with either cold or tepid water will be helpful. The cough is a 
troublesome symptom. Attention to the underlying irritation is de- 
manded, although one cannot hope to influence, to any great extent, the 
cough dependent on cavity formation. Catarrhal processes in the res- 
piratory tract can be lessened. Lesions that are acting as a cause of 
irritation, will frequently be found in subluxated ribs or vertebrae. The 
seventh and eighth dorsals are frequent sources of cough. The tissues 
about the pharynx and larynx, and the hyoid bone, disturbing the vagus 
and other nerves, should be carefully watched, also possible reflex irri- 
tation from the abdomen and pelvis. Night sweats are due to tuber- 
cular processes weakening the system and particularly lessening ner- 
vous control. These will subside as the body is strengthened. Spong- 
ing will be of service. Disorders of the stomach and intestines, such 
as nausea, vomiting and diarrhea, require treatment of the splanchnic 
area and regulation of diet. Considerable can be done to relieve tu- 
bercular laryngitis by careful treatment of the larynx and contig- 
uous tissues. Hemorrhage is Hkely to be self-Hmiting. Attention to 
the upper dorsal vertebrae and ribs and muscles will tend to equalize 
the circulation. Rest and use of ice upon the chest, as well as inter- 
nally, will be beneficial. 

Mclntyre, in an article on "Fat Food in Consumption," sums up 
the treatment for tuberculosis in the following words: "The treatment, 
then, for consumption should include rich, stimulating diet, proportioned 
to the digestive power of the patient, containing an excess of fats in most 
digestible form, of which sweet cream, fresh butter and well-cured bacon 
are the best examples, and the free use of pure drinking water, coupled 
with the promotion of blood flow, respiration and elimination of waste 
by osteopathic means." 

Surgical measures may be necessary where glandular or other tissue 
has broken down and is a menace to recovery. 

Spanish or Epidemic Influenza"^ 

By George M. McCole 

The epidemic of influenza which swept over the world and reached 
the United States in August 1918, starting in at the Atlantic sea-board 
cities, developed rapidly there and passed westward over the country. 
It reappeared the following winter. 

♦Rewritten from article in Osteopathic Physician, .June 1919. 



400 The Practice of Osteopathy 

Epidemiology. — In the United States it was called Spanish influ- 
enza, as it was at its worst in Spain at the time it broke out here and was 
thought to have been brought from that country. 

In Europe it was called the Uki-ainian influenza and in southern 
Russia it was said to have emanated from the Orient. No country in 
the world was exempt. It was at one time thought to be a type of the 
pneumonic plague and while plague is the severest toxemia known many 
cases of Spanish influenza were equally as prostrating and fatal as the 
ordinary type of pneumonic plague. The bacillus pestis was never proved 
to be the cause of this pandemic of influenza but the cHnical analog}^ was 
very evident. 

A study of European conditions of health and hygiene shows how- 
reasonable it is to beheve that some disease would develop and sweep a 
world lowered in vitality and immunity by the abnormal conditions of 
war. Every known communicable disease was raging in Europe and 
Asia where milHons of people existed under exceedingly poor hygienic 
conditions. 

The period of incubation of influenza was extremely short, averaging 
about two days. All ages were attacked, although persons over 60 rarely. 
Those between 25 and 35 seemed to be the most susceptible but it was, 
perhaps, because they were in active hfe and more exposed. There is 
considerable evidence that the disease was not air-borne but conveyed 
bj^ contact with active cases. The secretions of the mouth, nose and 
eyes were considered the active carriers. Masks, made of several layers 
of gauze fastened over the face, have been worn by many people but ex- 
perience taught that their use did not avail against infection. 

Mortality. — The mortahty under drug medication as shown in a 
statement bj^ Henry S. Bunting was as follows: "New York City 9.8%; 
Chicago 14.5%; Boston 27%. Osteopathy's influenza salvage repre- 
sents the difference between these figures and the low score of one fourth 
of 1%." He gives the following statistics on pneumonia following 
influenza under drug medication. "Reports from 148 health commis- 
sioners show an estimate (called conservative) of 33% of fatahties in 
epidemic pneumonia under medical care. In some large centers it ran 
as high as 68% to 73%. As officially compiled to date, the fatalitites in 
epidemic pneumonia in our army and navy cantonment hospitals 
amounted to 34^%. Osteopathy's fatahties were only 10% which in- 
cluded all those eleventh-hour appeals to Osteopathy. 

"The Chicago and New York departments of health figures, each 
show total death losses of 18% in all of their epidemic cases. Osteopa- 



The Peactice of Osteopathy 401 

thy's remarkable salvage of life is best measured from this point of com- 
parison. Its total death rate from both influenza and pneumonia has 
been actually less than one percent. " And this is based on 110,000 cases 
reported to the American Osteopathic Association. 

Pathology. — The pathology of Spanish influenza is practically a 
study of lung involvement. There we find an exudative pneumonia of 
a rapidly confluent type, a transudate of blood serum and red cells ap- 
pearing in the lower lobes of both lungs and rapidly flooding the entire 
space. Air bubbles were scattered through the serum soaked lungs, giv- 
ing a frothy appearance to some parts. At times some parts of the lungs 
showed drops of hquid pus. 

Where pneumonia did not develop there was no typical pathology. 
The toxins left an irritated bronchial tube, intestine or kidney just as in 
any other severe toxemia. 

Broncliial and the old type of lobar pneumonia also appeared as 
a comphcation of Spanish influenza, making three types of pneumonia 
which were to be guarded against. 

Symptoms. — The attack is usualty ushered in by a chill or prolong- 
ed chilly sensations, sometimes lasting for two or three hours; fever 
103° to 105° F. ; if it does not fall in three days or if it comes up after once 
falhng, pneumonia is to be suspected; pulse, full and bounding with a 
varjdng rate ; headache usually general in type and in severity from sHght 
discomfort to a most violent type; intense pain in the back and legs; 
tenderness the whole length of the spine but especially distressing in 
the upper dorsal, lower lumbar and sometimes the upper cervical; a dysp- 
nea which is best described as being a constricted feehng of the chest 
with airhunger; often the bronchial tubes are raw and dry, the patient 
feeling as if the breathed-in air were hot to the bronchial tubes, an active 
exudative bronchitis developing; sometimes there is an active bronchitis 
with distressing cough; nose bleed is a frequent symptom (and is often 
a sign of threatening pneumonia) ; most cases sweat more or less, some 
have drenching sweats; sleeplessness; albuminuria frequent. 

When the temperature breaks it practically always falls below nor- 
mal during the course of that day. A typical case of severe character 
often presents all of the above symptoms; the hghter cases perhaps only 
two or three of them, of which the chilly sensations, fever and bounding 
pulse are the most common encountered. 

A severe case is impossible to differentiate from the first symptoms 
of smallpox. Where a case of this type is encountered, it is always ad- 
visable to get history of vaccination or smallpox. 



402 The Practice of Osteopathy 

Examination. — The successful treatment of disease calls for atten- 
tion to little things. Some little thing properly cared for very often gives 
us our margin over adverse conditions and spells success in the care of 
our patient. 

During the epidemic I found a few cases which ran a temperature 
much below normal, sometimes as much as three or four degrees, and 
still with enough symptoms to be easily diagnosed as influenza. 

Pulse was taken at the time the thermometer was in the mouth. 
Pulse was practically always bounding and hard. Its rate varied widely, 
being influenced by many other conditions. I often, early in the attack 
and where other sjmiptoms were indefinite, made a diagnosis principally 
from the pulse. 

Respiration was taken while holding the watch and with the finger 
on the pulse so that patient would not know that breathing was being 
watched. 

Many patients complained of a sensation of weight on the chest 
and difficult breathing — hardly what one would term true dyspnea 
yet a real air hunger and sensation of constriction in the chest. The 
breath was often tainted with the odor of acetone, indicating a high de- 
gree of acidosis and giving an important diagnostic point. 

The heart was then examined, both by auscultation and percussion. 

The examination was then extended over the lungs and pleural rub 
hstened for. 

Patient was questioned as to having had a chill, general health, oc- 
cupation, undue exposure, fatigue, what physic if any, had been taken 
or other drugs used, bowel movements and bloody stools, food taken, 
sleep the night before, and dreams, headache and backache. 

The full examination could not be given at each call and not all of 
it to each patient, as time would not permit during the height of the 
epidemic. 

Throat was always examined. This is an important point. 

The urine was examined in a great many cases and often albumin 
and sometimes casts were found. 

Treatment. — I consider it advisable to give a strong deep treat- 
ment if the patient is seen before the attack has gained full headway; 
after that I give short fight treatments. 

If the disease has not developed much at the time of the first visit 
vigorous treatment with adjustment of the deep-lying and tightened-up 
hgaments over the spinal cord is indicated. Subsequent treatments 
are given to overcome the invariable and recurring contractions along the 



The Practice of Osteopathy 403 

spinal cord. The spine is gently sprung and the muscles pulled away 
from the intervertebral foramina so that arteries, veins and nerves of 
the spinal cord are free to function. 

I might note here that I consider Spanish Influenza does its damage 
through the attack of its peculiar and virulent toxin and the accompany- 
ing acidosis, on the body's reservoir of energy- — the spinal cord and re- 
lated structures, the vegetative glands and nerves. 

If the patient is in a serious condition he is often treated in the posi- 
tion in which found, so as not to disturb him. Care is particularly taken 
to keep a patient who is moist with sweat from taking cold or being ex- 
posed. An extra covering is thrown across the neck and shoulders, and 
pulled down as the bed covers are moved to get to the area to be treated. 

The musculature of the upper dorsal and cervical region is given 
special attention, the region of the first and second cervical and the 
first to sixth dorsal being special seats of trouble. The region between 
the spine and scapula on the left side, first to sixth ribs left, and the re- 
gion of the suprascapular notch on the left side are given specific treatment 
to free them of contractions. The tissues of the suprascapular notch 
are in direct connection with the nerve supply of the heart muscle and 
treatment here is astonishingly effective. 

This treatment for the heart is best given with the patient lying 
on the right side, leaning a little forward, with his left forearm against 
the chest, hand at neck or chin. Stand then at the patient's head and 
with the thumbs give all the region on the left side at the base of the neck 
and around the suprascapular notch thorough muscular adjustment for 
circulation and removal of contractions which disturb the heart's vital- 
ity. Treat first to sixth dorsal region. 

I consider this treatment specific for the heart debihty of infiuenza 
and many other heart conchtions, as well. I have found it especially 
effective in the weakened and nervous states following infiuenza and in 
so-called ''run down conditions" generally. 

Vibration with the tips of the fingers on the anterior chest wall is 
often used. Tender and contracted tissues are often found along the 
anterior ends of the ribs which are involved at their spinal ends. These 
are gently treated. Children are often given vibration, holding their 
chests with my hands under their arms. 

If the patient is stout and not easy to treat I have him sit up in bed 
and give the upper dorsal thorough percussion with the side of the hand\ 

1. This treatment was described by Henry M. Stovel, in The Osteopathic Phy- 
sician of January 1917. 



404 The Practice of Osteopathy 

About 100 strokes at each treatment are usually given. I remember 
one very fat patient in the eighth month of pregnancy to whom I could 
give hardly any other treatment. It was especially valuable here and we 
saved the mother after a hard fight, though the child was still-born. 

When nature is meeting the emergency and holding her own in the 
battle against infection we have a moderate fever — a benign fever. When 
the body is overworked with other duties and irritations the fever may 
rise dangerously high. Here it is that the physician must give further 
aid. Here it is that osteopathic treatment further aids by giving rest to 
the patient, easing pain and promoting general circulation (this in itself 
often quickly reduces fever). Here it is that the attention we give to 
clothing, diet, ventilation, quietness, good nursing, etc., comes in. The 
body is relieved of all duties but the one. Its functions are all turned to 
one end — the destruction of the invading infection. The osteopathic 
physician adjusts. Nature cures. It is all a matter of adjustment. 

For labored breathing, an effective treatment is to have the patient 
with hands clasped and arms raised above the head, patient being in 
bed, face up. Stand directly at head of patient. Reach over patient's 
arms and under the upper dorsal and lift up against the heads of the 
ribs with your fingers, thus raising the chest, beginning as far down the 
spine as you can and working up as you treat. Relax the muscles at the 
same time. 

Frequency and Amount of Treatment. — Frequency and extent 
of treatment depend upon the condition of the patient. In influenza 
the patient is approached with the idea of a dailj' visit. If then there is 
any doubt about his being entirely safe for 24 hours he is seen in 12 hours 
or as often as the condition indicates. Patients are usually seen more 
than once a day. 

The average time which the patients are confined to the bed is about 
five days. Some are free from fever in three days; some not for six or 
seven days. According to conditions they are then kept in bed from one 
to three days longer. 

As to the amount and length of treatment, I agree with James M. 
Fraser, who says adjustment of the soft tissues should be made and 
made with as Uttle disturbance to the patient as possible. He says^: 
"The ill effects of too long-drawn-out general treatments, or in short, 
over-treatment, I consider one of the most important questions for osteo- 
paths because I incHne to the behef that in many acute infections more 
harm may be done by such fatiguing over-treating than if the patient 

1. O. P. June 1919. 



The Practice of Osteopathy 405 

were really not treated at all. A "flu" or pneumonia patient should 
never be treated over fifteen minutes at the longest in one treatment. 
It is much better to treat often and not treat so long, as over-treatment 
may result from a desire to be thorough. If we always would stop and 
think what we are doing and just what we are trying to prevent we would 
be more careful when we treat these infectious cases. A patient's re- 
sistance may really be lowered, his bowels inhibited, his heart overstimu- 
lated, his muscles fatigued and his nerve force depleted by treating over- 
time. When the reaction begins, stop. " 

Congestions and contractions should be removed wherever they 
are found, be it in the region of the throat, spine, ribs, Hver or spleen. 
I order a daily enema and give positive instructions — after having had 
one or two almost fatal cases from this cause — to use no physics. Purg- 
ing killed more people here than any one other thing. If a heavy physic 
be given two or three times and the patient comes to a crisis, so much 
vitahty has been taken out of the blood that he does not have enough 
strength to carry him over and he dies. 

If the patient comes to pneumonia I find it good and effective to use 
the "constipation treatment." It is best to let the bowel take care of 
itself. Nature can do many things, and caring for the bowel in a crisis 
is one of them, providing the correct diet has been given the patient. 
If the patient is getting nothing but fruit juices there may be a natural 
bowel movement and even if he has been getting other food it is better 
to leave the bowel alone until after the crisis and then give the enema. 

A patient with a frank pneumonia following influenza has but little 
chance of Kving if his strength is being drained from the blood stream 
through the bowel every few hours. 

I see to it that no draft blows on the patient's bed. In a windy 
location a cold draft can appear suddenly and do great damage in a short 
time. The patient should not breathe cold air. Fresh air is all right but 
it must not be cold air. I order extra covering for the neck, arms, shoul- 
ders, back and chest. I Hke a wool workshirt best but use pneumonia 
jackets, extra undershirts, sweaters, etc., when the wool shirt is not to 
be had. In fact continued warmth seems to be an almost necessary 
condition to the proper handling of influenza. It is because heat, even 
the heat of the fever itself seems to aid the nervous system in building 
up antitoxins. 

The patient is instructed that if a sweat comes on, either from a 
hot bath, hot drink or as a result of the disease, to he and take it, for 
throwing off the covers is a sure way of taking cold and inviting pneumonia. 



406 The Practice of Osteopathy 

If the house is cold or the patient weak or very sick the urinal and 
bed pan are used. In fact I prefer their use even when those conditions 
are not present, as the less the exposure the less chance of pneumonia 
and the quicker recovery. Rest lying in bed is absolutely necessary to 
a satisfactory course and quick recovery. 

For lung congestions and bronchial irritation, in addition to osteo- 
pathic treatment along the spinal cord, raising the ribs and chest, and 
vibration of the chest wall, I sometimes use the old fashioned mustard 
plaster (made with one teaspoon each of flour and mustard, mixed with 
olive oil or with water and white of egg), keeping it on about ten to thirty 
minutes or until a good, red reaction is brought about. The feet must 
be kept warm with hot water jugs. A hot mustard foot bath is excellent 
when the feet persist in staying cold. 

At first I did not use the hot tub-bath. I am now ordering it if I 
see the patient early in the attack and where there is no contra-indica- 
tion, such as a dangerous heart condition. I do not use it unless it can 
be given properly and without undue exposure to the patient. I never 
give it late in the disease. 

A good method is to get the patient into the tub, lay two canes or 
sticks across the tub, and cover all with a blanket or rug. Place a bath 
towel for the head to rest on and pull the blanket around the neck. The 
patient can then take a good hot sweat in comfort. His arms and 
shoulders, his knees and legs will not be exposed to chill. When he gets 
up the blanket can be drawn about him if desired. He then goes back to 
bed for a good rest and sweat. A cold towel is placed on the head and 
water given to drink. 

Every patient should have a good sweat early in the attack. An- 
other good method is to cover with a blanket and place outside fruit 
jars or jugs filled with hot water, cold towel to the head and several glasses 
of water or lemonade to drink. 

The use of cold compresses on the chest I do not favor. They are 
used by some osteopathic physicians, but I believe the result is better 
with other methods. Apphed in a hospital where the technique is well 
in hand they might be successful, but personally I fear them. I am 
even careful about putting an ice bag on the heart. Cold packs are some- 
times used in my practice but only on the head for pain or dehrium. 
Chill must be avoided. Warmth must be conserved, even the fever is 
benign. 

Neither do I favor "rul>on" of camphor, turpentine or onions 
when they irritate the patient. If the patient has been used to them or 



The Practice of Osteopathy 407 

has faith in them and wants them I order them. I also order something 
of the kind where ''something must be done". When a family calls 
a doctor they "want something done," and it is best to do something; 
ever keeping in mind, however, that our patient's strength must be con- 
served. 

I do favor "rub-ons" in that I think it is well to keep the skin soft 
with some oil. It helps to keep an even temperature and the skin active. 
The skin should be wiped dry often, however, to remove the skin secre- 
tions which if left on become stale. 

I remember being called to see one Httle girl who could not get her 
breath, and found she was holding her nose with the bed clothes. She 
told me that the smell and stickiness of the lard and turpentine and the 
onions made her so sick and uncomfortable that she felt she could stand 
it no longer. When she was cleaned up, and clothed in nice clean white 
cotton she showed a wonderful improvement, and it was real as well as 
apparent. 

As to baths in influenza, I instruct the nurse to bathe the patient 
only as necessary for cleanHness and his comfort. DabbHng around in 
water is not a safe procedure in a disease where pneumonia is so easily 
contracted. 

I do not use alcohol rubs where the patient is in anything like a ser- 
ious condition, as alcohol closes the pores and dries out the skin. A 
rubbing or massage by the nurse is good for a restless, nervous patient, 
but it had better be done with oHve oil or some other good oil. In in- 
fluenza we do not want the pores closed. We need eHmination, and all 
we can get. A small saving of vitality or a little eHmination of toxins 
may be the margin that saves a patient for us. I do not favor the use of 
turpentine, for if it is absorbed it irritates an already sick kidney; if it is 
not absorbed it is useless. Why disturb the patient? 

For the bronchial irritation, in addition to osteopathic treatment, 
and the accessory mustard plasters, inhalation of steam is often used. 
A pan of boiling water is set by the bed and the patient leans over the 
edge of the bed with a bed-sheet or paper over the head and steam vessel, 
breathing the steam as long as it lasts. 

For the throat most any cleansing gargle can be used but I prefer 
the use of the connuon baking soda gargle. I have about one-half teas- 
poonful of soda placed in a glass and boiling hot water poured over it. 
As soon as this is cool enough to use I have the patient gargle thoroughly. 
The idea is to get the mouth, pharynx and tonsillar area clean and free 
from accumulations. Lemon-water gargle is often gratefully accepted. 



408 The Practice of Osteopathy 

If a very sick patient breathes through a dirty and dried-out mouth, 
all the stage is set for him to draw into the devitahzed lung large quanti- 
ties of infectious material. For this reason if not for the comfort of the 
patient it is necessary that the mouth be kept clean and also moist. 

It is not possible to kill this germ life with any antiseptic. The 
field must be made and kept clean. 

The nasal passage also should be looked after, to keep it clean as 
possible and also to allow the patient to breathe through the nose. 

For the nasal passage any good non-irritating oil is effective but I 
like best 2|% iodine in oil. It is a good lubricant and as far as possible 
we do get the germicical action of the iodine. 

Patients asking me what to do to avoid influenza are advised to keep 
the mouth clean and closed and to use the oily solution of iodine in the- 
nasal passages. 

And when treating the respiratory tract we must keep in mind the 
fact that all healing comes from the blood side of a membrane. No 
healing ever comes to a membrane from its exposed surface. Local 
treatment to a membrane must be a treatment which removes irritation, 
not one which adds more. Healing must come from within. "The 
rule of the artery is supreme. " 

Diet. — The diet used is Hquid, so that the digestive functions will 
be taxed as little as possible, for they are weak at this time. Fruit and 
vegeta]:)le juices only are used. 

The influenza germ propagates largely in the intestine and if the in- 
testine has in it the products of a full diet the bacterial growth soon 
overpowers the patient. Germ hfe cannot develop on fruit and vegetable 
juices. 

Another reason for using the liquid and fruit diet is that influenza 
is a disease running a short course and feeding is not necessary. If it 
were a disease such as typhoid, running a fever for several weeks, we 
would then give a more liberal diet, but the patient's strength will not 
be lost on a liquid and fruit-juice diet in three or even eight days. 

The frequency with which the urine contains albumin in this dis- 
ease shows us what a heavy load the kidneys are carrying. This makes 
a salt-free diet advisable and again brings fruit juice to our favorable 
attention. 

To activate the kidneys and thus reheve the headache we give always 
plenty of water and often hot lemonade. Orange juice and lemonade 
are used frequently as are blackberry, raspberry, pineapple, loganberry 
and grape juices. When the acid juices are not well borne we use non- 



The Practice of Osteopathy 409 

acid juices, such as pear and raspberry juice. A ripe, cooked pear mashed 
with a fork and mixed with one or two different fruit juices makes a satis- 
fying dish. 

Bottled sweet cider is also a most valuable food and a good bever- 
age. We use it in almost every case and find it the most acceptable to 
the patient of any food offered. I am of the opinion that apple cider has 
been neglected as an article of diet, both in disease and health, but espec- 
cially in fevers. It contains considerable iron for the blood, as well as 
having considerable food value. It has the added virtue of being pleas- 
ing to the patient. 

In addition to these juices we often use spinach juice. I have the 
nurse get a can of the best grade spinach and serve the juice hot, as a 
broth, with a httle salt and pepper and perhaps celery salt and a piece of 
bacon in it to flavor it and to appeal to the patient. Spinach juice con- 
tains much iron and iodine in a form readily absorbable by the blood. 
It also is useful in maintaining the alkalinity of the blood and body 
fluids, thus counteracting the acidosis of the disease. It renders the urine 
alkahne and thus relieves the kidneys of the irritation of acidosis and of 
an acid urine. Where the kidneys are or are Hkely to be involved the 
spinach juice must be served without salt. 

All the mentioned fruit juices tend to counteract acidosis and pro- 
duce alkahnitj^, but are not so effective as the spinach juice. They 
have the advantage, however, of being used in larger quantities. The 
spinach juice has considerable food value and has the added value of 
appealing to the patient's reason, when the iron and iodine content is 
explained to him. It is especially useful when treating those patients 
who are wondering if they should not be getting some sort of "tonic." 

The juice taken from ground fresh lettuce is also valuable. It con- 
tains more iron, iodine and phosphates than the spinach but it is not so 
easy to prepare. I have used it in the cases of several anemic and quite 
sick babies and consider it well worth all the expense and effort it took to 
secure it. 

Tlic breaking down of the alkahne reserve of the body and the con- 
sequent acidosis, comes early in the disease and is disastrous, and all 
I lie attention given to the diet is amply repaid in results. Careful at- 
tention to the diet is the only way the acidosis can be overcome. 

Raw fruit and vegetable juices also supply that most valuable ele- 
ment, vitamines. For this one thing alone is the raw fruit juice most 
valuable. I do not believe too much attention can be given to securing 



410 The Practice of Osteopathy 

a Kberal suppty of vitamines for the bod.y, especially during an attack of 
fever. 

Some especially interesting points are brought out by contributors 
to the Journal of the American Osteopathic Association in the March, 
1919 number. I wish here to add a discussion of these points. The 
contributors are physicians and good representatives of our profession 
and they report uniform and excellent success in handhng the recent 
epidemic. 

It seems to be the consensus of opinion that the treatment should 
be specific and light to avoid fatigue, with the possible exception of the 
first treatment, which often should be general and vigorous. 

All are agreed that the patient should be kept in bed, not even leav- 
ing it to go to the bath room. The patient must be protected in every 
way from fatigue and exposure. The enema was used by all. A num- 
ber of writers state plainly their opposition to the use of physics and 
laxatives. A hot tub-bath is recommended by several, but there is op- 
position to much bathing. 

Practically all the writers used the fruit-juice diet. However, 
a few gave a heavier diet and were successful with their patients, which 
is one more proof that the osteopathic treatment is the deciding factor 
in bringing about a cure. 

J. R. Thornton wrote after having had about 100 cases. He speaks 
especially of his cases of pneumonia. They resolved by crisis. There 
were no deaths. He says: "All cases were, preceding the first treat- 
ment, given a generous plain water enema. Orders were left for two 
enemas per day until told to discontinue, and in most cases the patient 
got the enema. A few cases, with the highest fever, the stationary fever, 
were given tap-water enemas, one each hour until the temperature drop- 
ped two or three degrees. 

"Sponge baths were given to reduce fever in every case. Diet 
was Hquid until the temperature was normal. 

"The osteopathic treatment of the usual spinal work, paying special 
attention to cervical and dorsal areas, and strong inhibition. 

"Pneumonia cases were treated three to five times a day and had 
as much time as they required at each visit. They required action. 
Heating compresses were used on each case, except the ice bag to the 
heart when rapid. One case of deUrium was treated with ice caps to the 
head and neck. Normal salt solution per rectum. Murphj' drip was 
given in each case. Diet, liquid consisting of egg-nog, milk, strained soup 
and broth. " 



The Practice of Osteopathy 411 

Maiy Alexander Patton: "Treatment should be quick, every 
motion significant so as not to tire the patient, for exhaustion is always 
present. Each patient was treated two or three times a day until temper- 
ature became normal. The nasal douche was given twice a day followed 
by K-Y jelly. Hot soap bath followed by soap enema and enteroclysis 
when fever persisted. " 

W. Curtis Brigham ordered "Hot packs the full length of the spine 
twenty to thirty minutes, three times a day. This will produce profuse 
sweating and often put the patient to sleep." 

I have used this same treatment, especially in nervous cases, and 
hold it in high esteem. I have the patient put a bath robe on backwards 
so that the arms and legs are well protected but the spine easily accessible. 
The hot packs can then be used and covered over and the patient not 
exposed. 

R. H. Nuckles maintains that lung and ear trouble will not follow 
influenza where osteopathic treatment has been given to adjust the 
cervical and upper dorsal circulation. 

H. A. Price: "We have kept particularly in mind, first, the nerve, 
blood and lympathic supply to the lungs; second, the circulation to the 
spine (meaning spinal cord); third, the internal secretory functions and 
to the general excretion." 

Ralph M. Crane says: "A great deal of my work is among the 
ItaKans. It was necessary to give quick specific treatment that I might 
do as much good as possible to the greatest number. I did not treat 
them as often as I would like to, and because of this fact I learned that 
osteopathy got control of the 'flu' immediately, the first treatment suffic- 
ing to start them on the road to recoverj^; in fact, many of them got no 
more than one treatment." 



412 The Practice of Osteopathy 



ACUTE ERUPTIVE FEVERS, MUMPS AND 
WHOOPING COUGH 

By Edgar S. Comstock 
GENERAL CONSIDERATION 

In the consideration of these diseases, it is well to bear in mind 
that lowered resistance is the primary condition that has made the in- 
fections possible, and that lowered resistance implies an imbalance of 
or obstruction to the vital fluids and forces of the body, thereby inter- 
fering with the functional activity of the body's normal protective mech- 
anism. 

The imbalance of or the obstruction to these vital fluids and forces, 
which is structural in nature, is produced by many conditions, as fatigue, 
exposure, sudden changes of heat and cold, emotions, dietetic errors, 
physical force or violence, etc. These conditions, because of the re- 
sponse of the tissues of the body to environmental changes, produce con- 
tractures of the elastic tissues, such as muscle, fascia, etc., which dis- 
turbs the structural integrity of the body and thus produces obstructions, 
irritations or intei-ference with the media of exchange of these vital flu- 
ids (blood and lymph) and forces (nervous energy) of the body. 

It is evident, then, that the most potent curative factor in the treat- 
ment of these diseases, as in all others, is the removal, whenever possible, 
of the obstructions and interferences that pervert the activity of these 
protective forces. It is necessary, therefore, to remove the exciting 
causes (fatigue, dietetic error, etc.) and by such physiological means as 
may seem necessary to readjust the structures of the body so as to re- 
move the above mentioned obstructions and interferences. 

The structural lesions most frequently found in the infectious dis- 
eases are of the muscular and fascial type and are very evident to the 
careful observer. The interosseous lesions are probably often the pre- 
disposing factors to the susceptibiHty of the softer tissues to reaction to 
environmental changes, but it has been the experience of the writer that 
the adjustment of the softer tissues was of greater primary importance 
in the acute stages of these diseases. The interosseous lesions may be 
easily adjusted in the very early stages of these diseases, that is before 
the severe symptoms have appeared, but after the more severe condi- 
tions have appeared it has been our experience that the soft tissue work 
was sufficient unless the interosseous lesions were very easily adjusted. 

It is the writer's desire to impress upon the reader the necessity of 



The Practice of Osteopathy 413 

careful attention to the structural lesions that are always constant in 
these diseases, using whatever physiological means seem necessary to 
adjust these lesions and keep them adjusted, and to insist upon carefully 
restricted diet; continuous, thorough ehmination of the waste products 
of the body; hygienic surroundings and well regulated environments both 
mental and physical. Then Nature, which has given the body its own 
protective mechanism, may have full control of the situation and all of 
the normal protective chemicals and forces in the body organism are 
utihzed in the battle with the invading infective forces: the glands 
secrete the chemicals of protection; the antibodies are rapidly de- 
veloped and thrown into the battle area; metabolism begins to return to 
normal; elimination becomes increased because of the stimulating action 
of foreign substances in the body structures; and the work of repair and 
recuperation begins. 

If rehance is placed upon the inherent protective forces of the body, 
the knowledge of the special type or character of the invading organism 
is of little importance from the standpoint of the treatment of the dis- 
ease after it has become established. The value of the knowledge of the 
specific organisms is in preventive medicine, in seeking out the habitat 
and breeding ground of the organism and its mode of transmigration. 
Knowing these, effective measures may be adopted to prevent their 
propagation and spread. Examples of this are Yellow Fever and Ma- 
laria. 

Variola 

(Smallpox) 

Definition. — Variola is an acute, specific, highly infectious and 
contagious, epidemic disease. Its beginning is sudden with a chill, 
vomiting, severe headache and lumbo-sacral pains. It has a typical 
fever curve and a typical eruption on the skin and mucosse of macules, 
papules, pustules and crusts successively. 

History. — Prevailed in China and India at least 1000 years before 
the Christian era. Epidemics occurred in the sixth century and during 
the crusades. Its first clinical description was given in Arabia during 
the ninth century. It was brought into Mexico about 1520 by the Span- 
iards and between three and four million people contracted the disease. 
In 1718 preventive inoculation was introduced into England and in 1796 
Jcnner discovered vaccination. 

Etiology. — The specific agent which is the cause of this disease is 
unknown, Init the virulence of the agents is retained for a long period 



414 The Practice of Osteopathy 

and is the most virulent found in all diseases. There is no period from 
the initial fever to the final desquamation that the disease is not con- 
tagious, although the stage of suppuration is the most violent. Although 
the disease is so highly contagious and the entrance of this particular 
poison into the system produces this disease, still no one has yet been 
able to discover a germ nor what the nature of the infective agent is. 
To contract the disease it is not necessary to touch an individual already 
afflicted, not to even approach the sick room. It may be only necessary 
to touch a garment that has once been in contact with a smallpox pa- 
tient, or which has simply hung in his vicinity. 

The blood is infectious at a very early stage. As smallpox is con- 
tagious without eruption it seems that the secretions and excretions 
convey the virus. The dried pustules seem to have the greatest infec- 
tiousness. Cadavers of smallpox (Variola) victims are very dangerous 
and relatives of them should be carefully warned. The disease often 
persists in infected communities for years. The disease is evidently 
spread by fomites, contact with the pustular contents, and crusts or 
scales of the desquamating skin. It attacks all classes, ages and con- 
ditions of people, which is unUke other erythematous diseases. 

A previous attack usually confers immunity. Vaccination is claimed 
to confer immunity but apparently in not all instances, for there are 
records of "successfully vaccinated" individuals having severe attacks 
of the disease. 

The susceptibihty to smallpox, as to all other infectious diseases, 
varies in different individuals, in different races, and under the influ- 
ence of conditions as yet unknown. Some persons are not susceptible 
to the disease, nor are they to vaccination, and yet others have been 
known to have had the disease as much as three times. The [egro and 
Indian races seem to be more susceptible than the Caucasian. Then 
again at intervals of a few years, the general susceptibility of the people 
seems to be increased so that cases of smallpox become far more numer- 
ous than usual. 

A point of considerable interest is the fact that the child, while in 
the mother's womb, may experience the disease along with the mother and 
thereby acquire, before birth, the usual immunity conferred by one at- 
tack of the disease. In most cases of smallpox in pregnant women, 
abortion or miscarriage occurs, yet a sufficient number of instances are 
on record in which healthy children have been born, exhibiting the char- 
acteristic pitting of smallpox, and possessing no susceptibility to vaccina- 
tion. Again there are other cases in which pregnant women have small- 



The Practice of Osteopathy 415 

pox and the babes in the wombs have escaped entirely; while the most 
singular fact is that while the fetus may experience the disease, the 
mother through whom the exposure was effected, escapes, either because 
of a previous attack or possibly because of vaccination. 

While there seems to be no reason for believing that an attack of 
smallpox can be, or ever has been, aborted by artificial means, yet there 
is a prevalent behef that this process occurred during certain epidemics 
of smallpox, cases having been known in which individuals presented 
all the symptoms indicating the invasion of smallpox, and yet no erup- 
tion occurred, and yet such individuals were thereafter insusceptible to 
smallpox or vaccination. 

The mortality of smallpox varies like the susceptibility of it — with 
the age of the patient and with some unknown conditions of the atmo- 
sphere or soil which favor the occurrence of the epidemics. The average 
in scattered cases — sporadic — is probably not greater than one in nine 
or ten. A fatal result occurs more frequently in the second week of the 
disease than at any other time. 

Pathology. — Granular and fatty degeneration occurs in the liver, 
spleen, kidneys and heart. Infiltration is found in the adrenal glands 
and testicles. During the papular stage, there is local hyperemia of the 
papillffi, with interstitial exudation and colhquative necrosis of rete cells, 
so that a vesicle is formed, peculiar in that it is traversed by delicate 
bands of epithelial cells. This, with the fact that coagulation-necrosis 
occurs mainly in the center, gives it the umbihcated, or depressed ap- 
pearance. The contents of the vesicle are plasma, fibrin and cell detritus. 
Leucocytic invasion converts vesicles into pustules. This has a more 
globular, elevated appearance than the umbihcated vesicle. Pyogenic 
organisms are found in the pus. When the inflammation injures the 
corium, scars are apt to result; this occurs when the skin is scratched. 
The actinic hght rays increase the danger. 

Diagnosis. — Mistakes in the diagnosis of the first cases of small- 
pox in an epidemic are almost inevitable. Hemorrhagic scarlatina or 
measles sometimes cause confusion; in the hemorrhagic scarlatina the 
mucous membrane hemorrhages are less frequent than in smallpox. 
The prodromal eruptions plus purpura arc very suggestive. The in- 
vasion stage lasts about three days. 

Smallpox is characterized by sudden onset with violent chill and 
shivering; agonizing pain in the back and legs; intense headache, mostly 
frontal; temperature rapidly reaching 102 to 104 degrees F.; full, strong, 
rapid pulse, going to 100 to 140; uncontrollable vomiting; pharyngitis; 



416 The Practice of Osteopathy 

red face, bright eyes, coated tongue; anorexia; constipation; sleepless- 
ness; delirium; often copious perspiration and extreme prostration. 

An "initial exanthem, " clearing within 24 to 48 hours, appears. 
It is either hemorrhagic or erythematous. About the third day the 
true eruption appears, first upon the forehead and in the scalp, then the 
rest of the face, the backs of the wrists, trunk, arms, and lastly the legs, 
most abundant upon the parts exposed to the atmosphere. With the 
appearance of the eruption, all symptoms abate, the temperature falls, 
and the patient may feel quite comfortable. The eruption consists of 
coarse, red spots upon the body, like flea-bites, rapidly becoming, within 
24 hours, slightly raised red papules, feehng hard and shotty to the touch, 
and each surrounded by a broad red inflammatory band, the areola. 
Usually by the sixth day the papules become converted into umbilicated 
^'esicles, at first clear, then turbid. They are hard and indurated to the 
touch, and on the eighth or ninth day the}^ become pustular. The areola 
becomes much darker, the temperature rises to 103 to 105 degrees F., 
and the pulse to 110 to 120. The other symptoms all reappear, with 
saUvation and delirium. Marked edema of the skin renders the skin 
unrecognizable. The pustules are painful, especially in places where 
the skin is thickened. The maturation lasts about three days, when the 
fever falls by lysis. If fatal, death usually takes place about the tenth 
day, preceded by feeble and more rapid pulse, marked dehrium, subsultus 
and sometimes diarrhea. About the eleventh day, desiccation begins, 
the pustules begin to dry, forming tight scabs which are closely adher- 
ent. The fever and other s}^nptoms subside but itching becomes an- 
no jdng. The odor from the pustular stage on is a pecuHar greasy one. 

After the rupture of large pustules the centers frequently dry and 
sink in, often in the shape of the Maltese cross. This is most typically 
seen on the backs of the hands and is pathognomonic. Toward the 
end of the third week the scabs faU, leaving red ghstening pits which 
disappear or change into deep white striated scars. The hair falls but 
may grow again. The diagnosis is not certain until the eruption is seen. 
In the smallpox without eruption the diagnosis must be made from the 
history of exposure, the presence of an epidemic, fever, lumbar and head 
pains, delirium, and possibly the initial rash. 

Mistakes in diagnosis may be made even by smallpox experts, but 
attention to the history, somatic findings and the course of the disease, 
rather than to the eruption, will prevent disastrous results. Always iso- 
late any and all suspected patients. 



The Practice of Osteopathy 



417 



Varicella Compared with Variola 

Vaccination and smallpox never Smallpox may closely resemble 
prevent cliicken pox; especially mild 

cases. 

Age — usiiall}^ before puberty, may Usually after puberty (many ex- 
occur in adults, ceptions.) 



Initial stage practically absent. 

Temperature, — no remission on 

onset of rash. 
White cells normal or decreased. 
Prodromal rash very exceptional. 
Vesicles in crops. 
Vesicles rarely shotty. 

Rash Evolution, — 

Very rapid, vesicles on first or 
second day. 

Eruption is universal, successive 
crops, most abundant on back, 
begins on body, less on face, 
scalp, hands and feet. 

Vesicle is superficial and fluid trans- 
parent. 



Initial stage severe, even in mild 
cases. 

Typical remission and secondary 
fever. 

Leukocytosis. 

Prodromal rash quite frequent. 

Vesicles never in crops. 

Vesicles, following macules, are 
hard and shott5\ 

Rash Evolution, — 

Much slovv'er, vesicles on seventh 
day. 

Development progresses down- 
ward, face first, then wrists, 
trunk, arms and lastly legs. Less 
on trunk. 

Fluid pearl-colored and not trans- 
parent. Thicker covering. 



Halo (areola) usually absent. 
Involution is quite rapid. 



Areola is marked. 
Involution is slow. 



The Secondary Toxic or Septic Rash appears during the stage of 
decrustation, sometimes with a mild fever. It may be either scarlatini- 
forin, morljilUform, or hemorrhagic. The skin immediately surround- 
ing the drying pocks is often exempt leaving an anemic halo. The rash 
lasts about three days and fades or desquamates. With the develop- 
ment of the skin eruption, an exanthem appears upon the mucous mem- 
l)ranes of the body cavities, developing into ulcers. This may develop 
l)of()ro the dermal rash and be of diagnostic importance. 



418 The Practice of Osteopathy 

Forms or Varieties 

^ ^^ . , ^, (a. Discrete. 

I. variola Vera < , /■. n 

( b. Confluent. 

I c. Purpura variolosa 
11. Variola Hemorrhag- S (black smallpox) 

ica. ( d. Variola hemorrhagica pus- 

tulosa. 
III. Varioloid. e. Smallpox modified by vac- 

cination or partial immunity. 

Discrete Variola Vera. — Incubation symptomless and averages 12 
days. 

Prodromal stage, from first symptom to eruption. Averages three 
days. The longer the stage the more severe the infection. Intensity 
bears Mttle if any relation to prognosis; however, if onset is mild, disease 
will not be confluent or hemorrhagic. 

Invasion begins with severe chill, often repeated. Initial fever 
rises suddenly to 103° or 104°, and reaches maximum on second or third 
day. Pulse is rapid and full. Skin is red, hot and dry. There may be 
sweating in the discrete form and in the favorable cases. The headache 
appears with the chill and is usually frontal. When severe and accom- 
panied with neckache and vomiting it may suggest meningitis. The 
backache appears with the chill and lasts about two days. It is a lumbar 
pain, ^'eiy hke lumbago; it occurs slightly less frequently than the head- 
ache and vomiting. This pain is rare in other fevers hkely to be con- 
fused with smallpox. Vomiting is constant in children and usual in 
adults. The initial eruptions, which are present in about 10 to 12 per 
cent, are of considerable diagnostic importance. They are usually lim- 
ited to the lower abdomen, inner side of the thighs, axillae, and some- 
times on the extensor surfaces of the knees and elbows. 

Tlie Eruptive stage consists of the following sub-stages: macules 
and papules; vesicles, and pustules. 

The macules and pa]iules occur on the fourth day and progress for 
about three days. They begin on the forehead, near the hair, with itch- 
ing and burning and resemble flea-bites. These soon become papules, 
which are reddish, elevated, circular, hard or shotty and discrete. On 
second day of this stage they appear on the body, and on the next day 
on the extensor surfaces of the extremities. If the eruption appears on 
the second day the confluent type may be anticipated; if on the third 
day of the disease, the discrete type. 



The Practice of Osteopathy 419 

The vesicles which occur on about the seventh day of the disease, 
contain lymph. UmbiUcation occurs in the centers of many of the ves- 
icles, and it is suggestive of smallpox. 

The suppurative stage begins about the ninth day with clouding of 
the vesicles and inflammation around them. This continues for three 
days. The pustules become opaque, then yellow, and a thick pus oblit- 
erates the umbihcation. The inflammatorj^ "halo" becomes more vivid 
and edema may follow around these haloes. This edema causes in- 
creased tension and deformity, particularly of the face, and produces 
great tenderness and pain. The pustulation follows in the order of 
eruption, from the face downward, and are the thickest on the extremi- 
ties and head. The pustules evacuate spontaneously, or may dry up 
without rupture. The skin gives off a peculiar, offensiye odor. Bed- 
sores are now most Hkely to develop. 

The eruptions also may occur in the mucous membranes, particu- 
larly in the mouth and nasopharynx. These pass through the successive 
stages as do those of the skin, but less typically. With the pustulation 
there is usually a gradually rising secondary fever. In the discrete 
type the secondary fever does not remain high more than twenty-four 
to thirty-six hours, with morning remissions. A marked leukocytosis 
occurs with the secondary fever and its extent depends upon the sever- 
ity of the infection Dilirium, albuminuria, acute exhaustion and heart 
paralysis are to be guarded against during this stage. 

The state of involution, or decrustation, begins about the twelfth 
day. It follows the order of eruption, and is accompanied with a de- 
crease in edema, redness and pain, but is attended with intolerable itch- 
ing. Crusts form, the hair falls out and by the end of the second week 
the temperature returns to normal. If fever persists during this stage 
it indicates some complications. Scars occur when the true skin is in- 
volved and lasts three or four weeks. Complete convalescence follows 
the disappearance of the last crust. 

Confluent Variola Vera. — This is a mahgnant type and used to be 
more prevalent than now. The initial stage is violent, and the headache 
and backache very agonizing. The fever remission is very shght or 
absent, and attended with hardly any improvement in symptoms. 
The earUer the exanthem occurs in variola the more likely it will be of 
the confluent type. The confluent eruptions occur especially upon the 
face and head, sometimes on the hands and feet. It is largely discrete on 
the body and extremities. Great edema appears with the fusion of the 
eruption, with the swelling and erosion of the mucous membrane, the 



420 The Practice of Osteopathy 

eyes close and the nostrils become obstructed. The fever is high,, pulse 
high and rapid (often irregular), dilirium, albuminuria, persistent nausea 
and vomiting, great thirst, husky voice, enlarged cervical glands, saliva- 
tion in adults and diarrhea in children are symptoms present. Death 
occurs from acute toxemia, usually within a week, but may last a little 
longer. Recovery from confluent variola is very infrequent. 

Purpura Variolosa. — This is "Black Smallpox." That is, small- 
pox with primary hemorrhage in the initial stages. It is the worst 
type and results almost invariably in death. It is very important be- 
cause it is so difficult to diagnose. Its incubation period is short (6 to 
8 days), invasion very severe, lumbar pains almost unbearable, pros- 
tration great, pulse soft, small and rapid and respiration unusually high. 
The initial pains and vomiting ma^^ last until death. 

On the first or second day a plum colored eruption appears, with 
brick-red, purple or inky ecchymoses particularly about the eyes. The 
condition is desperate. Hemorrhages may occur from any cavity of the 
body, sometimes accompanied by gangrene of the pharynx. The dis- 
ease does not usually reach the period of real eruption, because death 
usually occurs within four or five days. The diagnosis of this condition 
is by history of exposure to smallpox and the characteristic prodromes. 

Variola Hemorrliagica Pustulosa. — This is the type with the 
secondary hemorrhage, or the hemorrhage after the eruption appears, 
and is more common than primary hemorrhage. It occurs in weakly and 
alcoholic subjects. The initial stage is severe, and the hemorrhages occur 
into the vesicles or pustules. There may be epistaxis, hematuria and 
metrorrhagia. The outcome is almost always fatal, though the hemor- 
rhage at the vesicular stage may be followed by rapid abortion of the 
rash and recovery. 

Varioloid. — This is modified or mitigated smallpox; also known as 
variola benigna. Persons exposed to smallpox sometimes suffer from 
varioloid, and persons who have had smallpox may suffer from 
varioloid at subsequent exposure to smallpox. Vaccination appears to 
initiate an attack in persons pecuharly susceptible, or as a result of im- 
properly performed vaccination. The lesions remain in the epidermis, 
the course of the eruption is shorter, the papules vesicate by the fifth 
day, the process of suppuration is abridged, decrustation occurs rapidly 
with little or no scarring, and all symptoms are milder. There are many 
modifications. 

Other varieties are (1) Variola sine exanthemate, which has the 
usual symptoms without the eruption; (2) Variola verrucosa, which has 



The Peactice of Osteopathy 421 

large, solid, conical papules with small vesicles at their apices, which 
rapidly desicate and form crusts, and finally disappear without scars; 
(3) Variola cornea (horn pox) which is known by the large mahogany 
crusts. 

Complications and Sequelae. — Variola is often accompanied by 
many complications and sequalse which are an early severe toxemia and 
a later secondary infection. During the secondary fever, there may be 
bronchopneumonia, pleurisy, dysentery, hemorrhages of all kinds, ul- 
cerative eye, ear or laryngeal conditions, purulent arthritis, orchitis, 
gangrene when the swelhng is great and subcutaneous abscesses form, 
often attacking the penis and scrotum, erysipelas attacking the face, and 
rarely nephritis. 

During convalescence, carbuncles, boils and other subcutaneous 
abscesses are very common. Disturbances of the peripheral nervous 
system as neuritis, paralyses especially of the palatal muscles, neuro- 
retinitis, and otitis media are less common. The sequalse most common 
are boils, abscesses, deep pitting, otitis media, blindness and permanent 
baldness. 

The urine has the usual febrile changes. White islood cells reach 
10,000 to 20,000 or more. Lymphocytosis occurs during pustulation; 
polymorphonuclear cells are decreased to 40%, sometimes to 12%; 
myelocytes and irritation forms are found. During the febrile stage 
there is a polycythemia followed by an anemia to 3,000,000 or less during 
the pustular stage. Regeneration is slow, lasting about fourteen days. 
Normoblasts are rare except in hemorrhagic forms. Exudate taken from 
the pustules show streptococci, staphylococci, and psuedodiphtheria 
bacilli. 

Treatment. — The imperative demands of treatment are isolation, 
ventilation, cleanliness and disinfection. 

If symptoms are suspicious of smallpox, notify the proper author- 
ities at once and isolate patient. When diagnosis is made, cut hair 
and beard very short. 

1. Isolate patient in room free from draperies, rugs, carpets, cur- 
tains, pictures, etc. 

2. Disinfect all vessels used in room of the patient in carbolic acid 
solution or in bichloride of mercury solution. 

3. Family of patient should be isolated for from sixteen to twenty 
days. 

4. Room should be well ventilated, with windows screened and 
slightly darkened with red curtains to exclude the ultra-violet rays of 



422 The Practice of Osteopathy 

light. Temperature should be maintained at 65 degrees. Door- way- 
may be protected by a sheet dampened with a 1 :60 carbohc solution. 

5. Nurse must be robust, perfectly immune and not afraid. If 
male nurse, hair must be very short and must have no beard; if female, 
hair must be short and must wear close fitting cap. 

6. Absolute cleanUness is secured by plenty of baths, clean bed and 
personal linen, and careful nursing. Phj^sician must put on special suit 
with cap and gloves which are kept in the house, but not in the sickroom. 

The first sjinptoms being the headache, nausea and vomiting and 
the lumbar pains, the first points of attack in the treatment would be the 
relief of these pains in the head and back by thorough relaxation of the 
spinal muscles, paying particular attention to the suboccipital, mid- 
dorsal and lumbar areas. The headache may be partially relieved by 
steady pressure between the frontal and occipital regions. No inter- 
osseous adjustments requiring painful or difficult technique should be 
given after the more severe symptoms have appeared. Patient should 
be visited from one to three times per day, and the reflex contractures of 
the muscles must be relieved as often as they occur. 

Dysentery and diarrhea are controlled by strong inhibitory pressure 
in the sacral and lumbar regions. Give vasomotor treatment to the 
superior cervical ganghon. Stimulate the anterior aspect of the solar 
plexus to stir up its acid function, the blood being alkaline in smallpox. 

During all the stages up to the stage of pustulation, the patient re- 
sponds very readily and successfully to osteopathic treatment. The 
headache, the backache and the aching joints respond to treatment as 
readily as, if not more readily than, the headache and backache of in- 
fluenza do to osteopathic care. The constipation is usually quite readily 
relieved. It has been the experience of those who have handled small- 
pox cases, that the tendency to the confluent type is greatly reduced by 
this treatment and that the response of the patient to osteopathic treat- 
ment is very gratifying. Indeed, those of experience have less fear of 
the outcome of their smallpox cases than do they have of scarlet fever 
or pneumonia. 

After the pustules have formed, each pustule is treated with iodine 
painted on the pustule with a camel's hair brush. During the pustular 
stage it is not necessary to give manipulative treatment, and indeed it is 
sometimes impractical because of the tenderness of the skin. However, 
about all that is needed during this period is good hygienic treatment and 
good nursing. During convalescence constitutional treatment should be 
given. 



The Peactice of Osteopathy 423 

Diet. — During period of vomiting, pellets of ice in the mouth are 
comforting. During periods of fever give plenty of water with, prefer- 
ably, lemon juice. As the fever declines begin with barley and oatmeal 
water with lemon juice; then follow with easily digested and nutritious 
diet of milk, eggs, broths, beef juice and gruels. Feed every three hours 
during that period but not large quantities. During convalenscence a 
full, well-regulated, nutiitious diet should be ordered. 

Hygienic Care. — Keep nose cleansed with glycerine, cold cream 
or ohve oil, which keeps the crusts soft. The mouth and nasopharynx 
may be cleansed with any mild antiseptic. The eyes are washed with 
warm boric acid solution. Cold compresses applied over the eyelids 
assist in reducing the edema. A daily tepid sponge bath is necessary. 
Bath may be given with bichloride of mercury solution (1 :20,000) or 
creolin (1:500). 

Headache. — Deep, steady digital pressure in the suboccipital fossa 
and at eighth thoracic spine; ice bag to the head; or a mustard plaster 
at the back of the neck may relieve. 

Vomiting. — Thorough relaxation and adjustment of the great 
splanchnic and cervical areas, with deep, steady digital pressure in the 
occipital triangles, and at the fourth and fifth dorsal vertebra on the 
right side will usually control the condition. 

Fever. — Relaxation of the upper dorsal area, relaxation of the 
cervical area, and deep, steady pressure in the suboccipital region often 
reduce temperature. Warm sponging in lower grades of fever, bath at 
70° F., and cold pack may be needed. If temperature goes very high 
give a continuous cool colonic irrigation. 

Pitting. — Cold wet dressings of lint soaked in anj^ comfortable 
mildly antiseptic solution, or of ice water and glycerine, are to be used on 
the hands and face to prevent pitting. Hot water dressings are more 
comfortable to some patients. It is well to protect the skin from the 
light, especially from the ultra-violet rays. This, however, must not 
lead to any lack of ventilation. When crusts are forming keep them 
moist with vaseline, oil, glycerine, or carbolic acid in lanolin or vaseline. 

Odor. — Baths, the daily toilet and the use of dusting powder or 
o% iodoform powder, an open bottle of smelHng salts or of weak ammonia 
are good. Plenty of fresh air is best of all. 

Cardiac Weakness. — If pulse is feeble and frequent, a general 
quieting treatment should be given, including relaxation of the cervical 
area and of the fourth and fifth dorsal segments. An ice bag in flannel 



424 The Practice of Osteopathy 

directly over the heart is often very useful. Gentle, careful spinal ex- 
tension is very restful and eases the spinal circulation. 

Delirium is usually reheved, or prevented, by spinal extension, the 
prolonged warm bath or the cold pack, if given when signs of nervousness 
appear. Morphia or chloroform may be necessarj'^ in violent and sui- 
cidal cases. 

Laryngeal Obstruction. — Usually caused by edema and may re- 
quire tracheotoni}'. 

Bed-sores. — These and abscesses may occur even under the best 
of care. Place patient upon a water-bed or in a continued warm bath. 

Convalescence is not complete until the skin is entirely free from 
crusts and is perfectly smooth. 

Prognosis. — Prognosis depends upon age of patient; comphca- 
tions; and environment from which patient comes, as well as upon the 
nursing. In varioloid the prognosis is recovery; in the discrete variety, 
good; in the confluent type over 50% are fatal; in the mahgnant types 
practically all die. In patients under five years old and over forty years 
old the prognosis is very grave. A filthy environment predisposes to 
complications. Recurrences seldom occur; second attacks are usually 
varioloid. 

Prophylaxis. — Usual rules of health authorities are: rigid quar- 
antine or isolation, vaccination, disinfection of the skin and all fomites, 
and final fumigation. Quarantine of a suspected individual is sixteen 
days after exposure. Isolation continued until every trace of eruption 
has disappeared. The dead body is very dangerous and a public funeral 
is not permitted. The clothes used by the patient must be steamed 
and other articles must be washed with bichloride of mercury and fumi- 
gated with formaldehyde vapor. Disinfection of the hands, face, beard 
and hair of attendants with bichloride solution is imperative. 

Vaccination 

(Vaccinia ; Cow^-pox) 

Definition. — Vaccinia is an eruptive disease of the cow, com- 
municable only by inoculation and causing, when transmitted to the 
human being, local reaction in the form of a pock and constitutional 
disturbances which are followed by a more or less lasting immunity against 
small-pox. Vaccination is the artificial inoculation of vaccine virus for 
the purpose of producing an immunity against small-pox. 

Arm to arm vaccination was formerly very generally practiced but 
has been practically discontinued because of the possibihty of mfection 



I 



The Practice of Osteopathy 425 

from syphilis and other infections. When it is necessary to use the human 
l3Tiiph it should be taken upon the eighth day from a typical unbroken 
vesicle in a perfectly healthy child at least three months old. The vesi- 
cle must be pricked at several points, care being taken not to draw blood. 
The bovine vaccine l>Tnph is now in general use because it practically 
ehminates the possibiHty of syphiHs and other infections. Also because 
it is more easily traiisported. 

It is thought best by many authorities to vaccinate in infancy after 
the sixth month, at the seventh and eighth year, at puberty, and there- 
after at intervals of about seven years, but depending considerably on 
the prevalence of small pox. The virus is prepared under sterile condi- 
tions from carefully selected and tested calves. It is put up under asep- 
tic conditions in hermetically sealed capillary tubes or, in the old style, 
on ivorj^ points. 

There is a great variety of opinions as to the efficacy of vaccination 
in producing immunity against small pox, this variety of opinion being 
very prevalent among representatives of the medical schools. Dr. F. 
P. Millard of Toronto says the lymphatic system is the keynote, and that 
vaccine virus poisoning spreads through the lymphatics, causing diph- 
theria and allied throat affections. Dr. A. T. Still said, "We are opposed 
to vaccination." He repeatedly emphasized the fact that "Nature 
furnishes within the body all the remedies necessary to cure disease." 
In the recent Canadian epidemic (1919-1920) the medical authorities 
have met with a most strenuous opposition. The Homeopathic profes- 
sion, almost to a man, went on record as opposed to compulsory vac- 
cination. The Illinois Supreme Court has ruled that compulsory vac- 
cination is unconstitutional. 

Technic. — The area usually selected is the left arm at a point 
above the insertion of the deltoid muscle. Some prefer the leg over the 
junction of the two heads of the gastrocnemius muscle, because it is more 
easily cared for, and, because of the style of wearing short sleeves among 
women, it does not expose the scar which results from the vaccination. 

The surface must be washed, dried, with a soft towel, and then 
stcrihzed with alcohol. With a sterilized needle or lance scratch an 
area about a quarter of an inch in diameter, being careful not to produce 
bleeding but merely an oozing of pinkish lymph. A drop of the virus 
should be deposited upon the abraded surface, rubbed in with the 
side of the needle and let dry. A thin layer of sterilized gauze should 
be lightly applied and held by means of adhesive plaster, not encircling 
the limb. This should ])e occasionally removed and redressed. The 



426 The Practice of Osteopathy 

pock should be kept dry and clean, and may be lightly dusted with starch 
or toilet powder. "Persons exposed to the contagion of small pox should 
be immediateh' revaccinated. The immunity conferred diminishes 
with time." It is the writer's personal opinion that, with the amount 
of complications that so frequently follow vaccination and with the fact 
that "it is necessary to revaccinate during an epidemic or after exposure, " 
it were better to defer vaccination, if parties are favorably incHned to 
the practice, until such time as the presence of small pox in the commu- 
nity make it apparently necessary. 

Typical Vaccination. — The period of incubation varies from 
three to five days. At the end of this time local reaction shows itself 
in the form of reddish papules at the point of inoculation. In about 
five days these develop into compound vesicles, which at first have 
clear and then later opaque contents. About the eighth day the vesicle 
is fully developed and is round or oval with prominent and well defined 
edges and a depressed center. An erythematous areola usually appears 
about the tenth day and the contents are purulent. The surrounding 
skin is swollen and tender, and a scab now begins to form in the center 
of the pock and rapidly extends toward its edges. About the end of the 
second week the areola fades, and the pock is changed into a thick brown- 
ish crust which becomes dry and hard, and comes off between the twen- 
tieth and twenty-fifth da3'S after vaccination. A dusky red scar is left 
and this gradually becomes white and pitted. During the evolution 
of the pock the glands through which lymphatic drainage takes place 
become shghtly enlarged and tender. 

The constitutional reactions are usually moderate fever, restless-, 
ness at night, irritabihty and loss of appetite. These symptoms usually 
appear about the fourth day and continue about three to five days. At 
an}^ time during the vaccinia erythema, roseola or urticaria may appear. 
The constitutional reaction in revaccination is sometimes very severe. 

There are many atypical symptoms following vaccination as var- 
iation in the number of the pocks, in the size, in the severity of the con- 
stitutional symptoms, in the contents of the pock, in the healing and for- 
mation of the scar and in the transmission of specific diseases as sj^philis, 
tuberculosis, leprosy, cancer and tetanus. 

Complications. — All cases are not benign, as due to impurity of 
vaccine, carelessness in technic, improper care in dressing, handling of the 
wound by the patient himself, scratching it with the finger nails, and 
other accidents of like nature, infections may set in and very serious 



The Peactice of Osteopathy 427 

complications arise. These result in abscesses, erysipelas, tetanus and 
various eruptions. Otitis media may leave deafness. 

The writer knows personaU}^ of a young man in the Army during 
the World War who was vaccinated while in the Army and two abscesses 
developed which ate entirely through the arm, one abscess passing 
through the arm just anterior to the humerus and the other just poster- 
ior to it. It was many, many months in heahng, and nearly caused loss 
of the arm. 

There are many cases of record where vaccination was followed, di- 
rectly or indirectly, by paralysis, deformities, and chronic constitutional 
diseases. It is usually claimed these conditions were due to accidents 
following the vaccination and not due to the vaccination itself. How- 
ever, it can not be denied that the vaccination was at least the indirect 
cause of these deplorable conditions. 

General Vaccinia. — (Vaccinal eruptive fever; Vaccinola). This 
consists of a vaccine rash, developing usually from the fourth to the 
tenth day following vaccination, and appearing in various parts of the 
body, particularly about the wrists and on the back. The secondary 
pocks usually develop about the eighth or tenth day after vaccination 
and are usually more abundant on the vaccinated limb than on any 
other part of the body. As the pocks appear in successive groups, all 
stages of the disease may be seen at one time, and the condition may 
last for many weeks. Fever may be absent or present, but is usually 
proportionate to the extent of the eruption and the associated com- 
phcations. 

Treatment. — After vaccination, the patient should be told to 
return in seven days, when the dressings should be removed, and if the 
vaccination has been successful, a pearl-like vesicle will be present. If 
the vesicle has been broken by accident or by rubbing of the gauze, the 
free portions of the dressing should be cut away and the adherent part 
left undisturbed. A new gauze should be applied in any case, and in 
five or six dsbjs more, the dressing should be again changed, and this 
changing continued at intervals until the crust falls, which is usually 
during the third or fourth week. 

If no vesicle forms by the tenth or twelfth day, the vaccination has 
not been successful. It is suggested by the vaccination advocates that 
another attempt should be immediately made. 

Prognosis. — Uneventful recovery is to be usually expected. Pit- 
ting from generahzed vaccinia; various constitutional diseases; paraly- 
ses and other maiming disabihties sometimes occur. While it is not us- 



428 The Practice of Osteopathy 

ually considered dangerous to life, there are nevertheless many cases 
of record where death has resulted. It is not wholly unattended with 
danger. 

The best of care should always be taken following vaccination to 
prevent the possibility of comphcations, though even then they do occur. 

Scarlet Fever 

(Scarlatina) 

Definition. — Scarlet fever is an acute, specific, contagious, infec- 
tive disease of unknown origin, characterized by very sudden onset, fever, 
vomiting, sore throat and diffuse exanthem. 

History. — It was first recognized in the sixteenth century, but first 
fully described and differentiated from measles bj^ Sj^denham in 1660. 
It was introduced into America about 1735. 

Etiology. — The causative organism or agent is unknown. The virus 
of scarlet fever produces severe necrosis, but no suppuration. The 
streptococcus is the most important factor in the production of compli- 
cations and in their mortahty. It is claimed to be the cause of the ma- 
lignancy of the disease but not of the disease itself. Susceptibihty to 
the disease is by no means universal as only 38% of children and but 
5% of adults exposed to the infection acquire the disease. Over 90% of 
the cases occur under ten years of age, and rarely during the first year of Kfe. 

"Scarlet fever is a toxic superficial expression of internal malnutri- 
tive conditions of the blood as a tissue. The cause of the toxicitj' is 
usually over-feeding, or the feeding beyond the demands of the proxi- 
m.ate principles of the body, or the over-feeding under unhygienic con- 
ditions. " — J. Martin Little john", 

"It was once held that the virus was disseminated during des- 
quamation, but oral, nasal and otitic discharges probably perpetuate 
the infection, perhaps months after scaHng is complete. In no other 
disease is the virus so tenacious. It may persist ten years on clothes, 
furniture, etc. " — A. R. Edw^ards. 

The light forms are as contagious as the severe ones, and inocula- 
tions have occurred from the hving subjects as weU as from autopsy 
cuts. In degree of infectiousness smallpox ranks first, measles second 
and scarlet fever third. The infection may be spread b}^ any third per- 
son or by articles coming in contact with the patient, and often the mode 
is obscure. Sporadic cases apparently frequentty appear. The reason 
for the sporadic cases may easily be explained by the theory of J. Martin 
Littlejohn, given above. One attack usually confers immunity, but not 



The Practice of Osteopathy 429 

always. This disease occurs more often in the autumn and winter, and 
is more prevalent in cities than in the country. (Measles is more preva- 
lent in the country.) Scarlatina sometimes occurs with other infec- 
tions, such as diphtheria or measles, and more rarely with varicella, per- 
tussis, etc. 

Predisposing Factors. — Age, one to ten years; lowered resistance 
from over-feeding, unhygienic environments, exposure to sudden tempera- 
ture changes; lesions, both muscular and interosseous which interfere 
with the distribution of the fluids and vital forces of the body; season 
of the year (autumn and winter); puerperal women, and wounds. 

Pathology. — No specific lesions are found. No trace of the rash 
shows after death except in the hemorrhagic form. The anatomical 
changes in cases coming to autopsy are those of simple inflammation, 
follicular tonsillitis, or diphtheroid angina. Streptococci are abun- 
dantl}^ found in the glands and foci of suppuration. 

Symptomatology. — Scarlet fever is divided into four stages: 
(1) Incubation, (2) Invasion, (3) Exanthem, (4) Desquamation. 

Incubation Stage. — Has no noticeable symptoms and lasts from 
two to four days. Some authors claim as high as ten to fourteen days. 

Invasion. — The invasion lasts one day. The onset is very sudden 
beginning with a chill which is followed by a characteristic vomiting, oc- 
curring in 75% of the cases, which is more frequent than in any other 
disease of childhood except pneumonia. 

The vomiting is followed by headache and the beginning evidence of 
sore throat, which usually soon develops into a tonsilHtis. The severity 
of the sore throat is indicative of the severity of the scarlet fever that 
follows. The temperature suddenly rises to 103° or more, the pulse 
becomes unduly rapid for the temperature, 120 to 160 per minute, and the 
respiration is increased. The skin begins to burn, there is dysphagia and 
intumescence of the cervical glands. The muscles of the back become 
hypersensitive to touch and to extremes of heat and cold; and particu- 
larly sensitive spots are found over the transverse processes of the first 
to 4th cervical vertebrae, the 4th and 5th dorsal and the 11th and 12th 
dorsal vertel^ra). At these points will be found intensel}^ contractured 
tissues which must be kept relaxed. 

Exanthem. — The eruption appears at the end of the first day or 
early the second day, showing first over the clavicles and on the neck, then 
over the upper trunk, next the lower trunk and Hmbs. The eruption on 
the extremities appears particularly over the flexor surfaces of the joints. 
By the end of the second day the eruption has^covcred practically the 



430 The Practice of Osteopathy 

entire body, leaving a white circle about the eyes and mouth. The erup- 
tion pales, or disappears on pressure, quickly returning to the scarlet 
color on the removal of the pressure. Frequently, the skin itches and is 
very uncomfortable. 

A punctiform eruption in the arm-pits, over the groins, or on the roof 
of the mouth is considered positive proof of scarlet fever. 

The eruption at first consists of small red spots which fuse as the skin 
swells and results in an intense lobster-colored erythema. This lasts 
four to six days. The tongue, at first, is red at the tip and margins with 
a greyish-yellow or whitish fur in the center through which is often seen 
the swollen red papillae, the "strawberry tongue." The "fur" des- 
quamates on the third or fourth day, leaving a surface intensely red 
with marked raised, swollen papiUa?, the "raspberry or cat tongue," 
which lasts nearly a week. The breath has a heavy, sweet odor. The 
pharynx, u\aila and tonsils become swollen, and often creamy-white 
patches cover the mouths of the tonsillar folhcles. 

Between the second and third day the eruption reaches its height, 
when it has a vivid scarlet hue unUke any other eruption, and becomes 
darker each day until it ma}^ be a bluish-red, when it gradually fades and 
desquamation begins. By the seventh or eighth day the rash has dis- 
appeared, together with the fever. 

Desquamation. — Scahng begins on the face first, from the sixth 
to the ninth day and lasts several weeks. The skin looks somewhat 
stained, is a little rough hke "goose-flesh" and gradually the upper layer 
begins to separate, and the scaling begins in large lamellae or flakes. 
Casts of the fingers or toes may be shed. The swelhng of the glands dis- 
appears, and the fever falls by lysis, and convalescence begins, unless 
complications intervene. 

Diagnosis. — In typical cases diagnosis is easy, especially during 
epidemics or when the eruption is accompanied by other criteria. 

1. Sudden onset, with nausea and vomiting, sore throat, quick 
appearance of fever and rapid development. 

2. Punctate spots in the throat, swelling and dysphagia are usually 
present. The severe sore throat symptoms with the above are always 
very suspicious. 

3. Strawberry tongue is constant. 

4. Eruption, typical in character, appearing on second day, first 
showing on the neck above the clavicles, intense on the body and prac- 
tically absent around the mouth. Eruption confluent, with no inter- 
vening free areas of the skin, followed by desquamation. 



The Practice ^of Osteopathy 431 

5. Lymphadenitis much more pronounced in the inguinal and 
other glands than in the cervical. 

6. Desquamation, tender joints and albuminuria will force the 
conclusion of scarlet fever, if former symptoms have been indefinite. 

In the atypical cases we may have very light attacks with all the 
symptoms present but very poorly developed ; or some symptoms absent 
as in cases with no temperature, or others with no rash. Some cases are 
so atypical as to be impossible of diagnosis. The writer has very recently 
had the experience of one case when there were absolutely no typical 
symptoms present after being called on the case, but four days after 
the invasion of the disease in the patient a sister of the child developed 
typical scarlet fever, and not until the sixth day did any eruption or sore- 
throat appear, and then the eruption was more characteristically measles 
than scarlet fever. Consultants with the writer agreed with him that 
the case was one of an atypical, non-eruptive scarlet fever. 

Differentiation. — Scarlet fever is not always easily differentiated 
from other diseases, such as a septic rash, drug rashes, diphtheria, measles 
and German measles. 

A. R. Edwards gives this differentiation between scarlet fever and 
septic rash. 

Scarlet Fever Sepsis. 

Bright red erythema, with small A very deep purple-red rash, some- 
red papules, times spreading over the entire 

body. 
The eruption is much the same in 
both diseases, the same places 
being exempt. 
Miliaria are rare. Miliaria are frequent. 

Rather typical desquamation. JDesquamation observed less fre- 

quently. 
Criteria: angina, tongue, onset. Etiology, chills, sweats, fever ir- 
glands, etc. regularity, polymorphous exan- 

thems, etc. 

Diphtheria. — Often difficult to differentiate. The simple erythema 
is sometimes observed in diphtheria, but is darker, more on the trunk, 
and more transitory than in scarlet fever.Jgj 

Drug Rashes. — These rashes are caused by belladonna, iodoform, 
quinine, iodide, chloral, copaiba or aspirin. They may be easily dif- 
ferentiated if the cardinal symptoms of scarlet fever are considered in- 



432 The Practice of Osteopathy 

stead of the rash alone. At the present time, perhaps the most fre- 
quent drug rash that we meet is that produced by aspirin. It is some- 
times hard to diagnose because the aspirin has been taken for a sore 
throat or tonsilUtis. which so resemble the early symptoms of scarlet 
fever. 

Measles and German Measles.— The symptoms of the invasion 
stage of these diseases is sometimes quite similar, and even the rash may 
be quite similar: the differentiation will be discussed under measles (q.v.). 

Types and Forms.— (a) Mild and abortive form (scarlatina sine 
eruptione). In this the rash may be scarcely perceptible, while the fever, 
sore throat and straw-berry tongue are present. Desquamation may be 
present and it may be followed with a severe nephritis. 

(b) Mahgnant forms, (1) Atactic variety, violent intoxication, 
onset of great seA-erity, fever very high (107° to 108°), extreme headache, 
delirium, and often convulsions. Initial dehrium gives place to coma; 
dyspnea may be urgent; pulse very rapid and feeble; and death occurs 
before eruption appears. (2) Hemorrhagic variety: there are hemor- 
rhages into the skin, beginning with scattered petechiae, becoming more 
extensive and ultimately involving the whole skin. It is characterized 
by severe fever and brain s:yTxiptoms at the onset; incomplete exanthem, 
necrosing angina, marked glandular and splenic sweUing; subcutaneous, 
serous and mucous membrane hemorrhages with ulceration. Death 
may take place on the second or third day. This is more common in 
enfeebled children, although it may attack adults in apparently full 
health. 

(c) Anginose form (Scarlatina anginosa.) This form resembles 
septic diphtheria, with marked toxemia, necrosis and adenitis. The 
throat symptoms appear early and progress rapidly. Temperature 
high, cyanosis, diarrhea, rapid weak irregular pulse, and stupor occur. 
The fauces and tonsils are covered with a thick membranous exudate 
which may extend to the posterior wall of the pharynx, forward into the 
mouth, upward into the nasal chambers, and may occasionally reach the 
trachea and bronchi. The Eustachian tubes and middle ear are usually 
involved.. The glands of the neck rapidly enlarge and become the seat 
of brawny induration, and the inflammation extends beyond their hmits. 
Necrosis occurs in the tissues of the throat, fetor is extreme, the consti- 
tutional symptoms are great and the child dies of toxemia. If he does 
not die, extensive abscess formation in the tissues of the neck takes place 
with sloughing and danger of hemorrhage from the opening of a large 
artery. 



The Practice of Osteopathy 433 

Blood Pressure. — ^Rises at first, thereafter it follows the pulse and 
temperature. After the seventh or eighth day it may be below normal. 
Cases of albuminuria show hyperextension and slowing of heart action. 
With the subsidence of the kidney irritation the pulse rate is increased 
and the blood pressure returns to normal. 

Urine. — Shows ordinary febrile character, being scanty and high 
colored. Slight albuminuria is rather common after the stage of eruption, 
even a few tube casts may be present without any serious irritation of 
the kidneys. Urinalysis should be made daily. 

Blood. — The red cells are moderately reduced to 3,000,000 or 
4,000,000 per c. mm. during convalescence. There may be some poikilo- 
cytosis, and normoblasts are occasionally seen. Leucocytosis is early, 
15,000 to 30,000 per c. mm., faUing with the decUne of the fever usually 
by the fourteeneth day, but may persist for weeks after the temperature 
is normal. The count runs roughly parallel to the temperature. Over 
40,000 leucocytes per c. mm. are of bad prognostic omen. Polymorpho- 
nuclear cells are increased to 80% or 90%; early returning to normal in 
favorable cases. 

Eosinophiha is present in all but malignant cases. It reaches its 
maximum two or three days after the rash appears and returns to normal 
after the leucocytosis has disappeared. The early presence of eosino- 
phiha excludes septic conditions. When these cells are absent in scarlet 
fever, myelocytes are to be found. 

Treatment. — Chnically scarlet fever represents, from the osteo- 
pathic viewpoint, (a) a toxic condition due to internal malnutrition and a 
decrease of the detoxinating function of the thyroid gland; (b) secondarily 
associated with the sore throat is a type of toxic tonsillitis, but it is due 
to the toxic elements in the blood; (c) in the lesion field it is associated 
with extreme stiffness and muscular tension in the upper cervical area 
and also in the entire dorsal area, overlapping the upper lumbar. The 
eruption is a superficial expression of the attempt of the body to ehminate 
the toxins, and this ehmination should be aided by enhancing the activity 
of all the other ehminative functions. Cases are on record where pa- 
tients have been exposed to scarlet fever, have gone the usual incubation 
period and developed the invasion symptoms, and by thorough, oft- 
repeated osteopathic treatments, with the aid of enemata and copious 
hot water drinking, have not gone beyond the invasion period and the 
disease apparently aborted within two or three days. It is therefore well 
to give thorough, oft-repeated attention to these cases during the very 
early stages. 



434 The Practice of Osteopathy 

(1) In all cases where the first symptoms indicate the possibiUty 
of a contagious disease, the patient should be immediately isolated and 
kept isolated until all danger of contagion is past. In scarlet fever casess 
get a competent nurse. Keep room light, quiet and thoroughly venti- 
lated with a constant temperature of as nearly 70° as is possible. (It 
were better to have two rooms if possible, one for day and one for night: 
have room or rooms on upper floor if in a house). Arrange suitable 
means for thorough disinfection of all articles used in the sickroom. 
These are very essential. 

(2) Patient should be clothed in usual night wearing apparel. The 
bed clothing should be warm, but not heavy. The physician should wear 
an operating gown or a sheet which thoroughly covers his clothing, also 
a cap. He should carefully wash his face and hands immediately after 
leaving the sickroom. The quarantine should be maintained for the 
legally required period, and even after if there continue discharges from 
the nose, nasopharynx or the ear. Bichloride wrappings should be placed 
about the body of the dead, and funeral must be private. 

(3) Have enema given immediately to cleanse the lower bowel. 
Follow this with frequent draughts of hot water, or better hot lemonade 
for the first day. Place hot water bottles at feet. If eruption is slow 
in coming out, it may be aided by a hot bath, followed by wrapping the 
patient in warm blankets to prevent chilling. 

(4) Thorough osteopathic treatment should be given along the 
entire spinal area from the atlas to the sacrum, inclusive, to keep the 
muscles well relaxed, giving special attention to the relationship of the 
vertebrae and the tension of the muscles from the occiput to the fourth 
cervical; the third to the sixth dorsal; and the tenth to the twelfth dor- 
sal areas. Also give special attention to the deep cervical muscles, 
particularly those at the angle of the inferior maxilla, and at the articu- 
lation of the inferior and superior maxillae. Remember the tendency 
of the kidneys to complication in scarlet fever, therefore do not neglect 
the renal splanchnics, for here you not only control the renal functions 
but also regulate the adrenal functions and their internal secretions. 
Keep the clavicles properly adjusted and articulate them by bringing 
them well forward to relieve any irritation that may have started in 
that area. Careful direct treatment to the abdomen should usually be 
given at each visit besides the work in the splanchnic area to keep the 
bowels, kidneys and Hver active. 

Diet. — Water must be given freely. If fever is very high, pellets 
of ice held in the mouth will give comfort. During the height of the 



The Practice of Osteopathy 435 

fever it is preferable to withhold all nourishment, but if in a particular 
case it seems to be indicated, confine the nourishment to fruit juices, 
especially oranges. Never force feeding during the fever. For infants 
cut down their feeding to at least 'half, making the milk very thin with 
water or gruel. After defervescence, carefully increase to a hght diet 
using sparingly of nitrogenous foods except milk. After four weeks in 
the usual case, gradually return to the ordinary diet. This is a good time 
to make corrections in the ordinary diet if any are needed. 

The bowels must be kept regulated. An enema is usually indicated 
after the onset of the disease. During the time that food is permitted it 
should be of a laxative character. During the fever stage the enema 
should be given daily to help keep the bowel cleansed and to help reduce 
the temperature. If bowels are persistently sluggish and the fever is 
constantly high the abdominal heatmg compress (so-called "cold com- 
press") will give much relief. 

The nose and throat should be constantly looked after. The nose 
may be cleansed by instillation by means of a medicine dropper, using 
normal salt solution. If the throat symptoms are mild, a gargle of warm 
normal salt solution is enough for cleanliness of the membrane. If the 
throat symptoms are too severe to permit the use of the gargle, or if the 
patient is too small to be taught the use of the gargle or to \ ash the 
throat, irrigation may be employed. The use of raw lemon juice, or of 
raw pineapple juice, on a cotton swab is of great value in cleaDsiijg the 
tonsils and throat. The swabbing should be repeated several times 
per day. 

The teeth should be carefully and thoroughly cleansed twice per 
day. 

The skin must be constantly cared for. During the fever it is well 
to cover the skin with linen or soft cotton. Daily sponge baths of car- 
boHzed water (1:40) of tepid temperature followed by applications of 
cocoa-butter will give much comfort. Use only good toilet soap and do 
not use the so-called antiseptic soaps because, authorities claim, there 
is a chance of renal injury. During the period of desquamation the use 
of the cocoa-butter will assist in limiting the source of infection by pre- 
venting the diffusion of the dry scales which are considered infectious by 
many physicians. A. R. Edwards says: "During desquamation, oil- 
rubs were once employed to decrease the dissemination of dry scales, but 
they decrease the function of the skin, which is of great importance 
when the kidneys are involved; also, infection is carried by means of 
throat secretions. Soap and water serve equally well." Some authori- 



436 The Practice of Osteopathy 

ties suggest that during the desquamation, after bathing the patient, 
the skin should be thoroughly rubbed and then the oih" application used, 
using cocoa-butter, unmedicated cold cream, hquid albolene or the like. 
Olive oil and vasehne are usually irritating. The writer inchnes to the 
opinion that the soap and water bathing is sufficient, except perhaps 
the use of cocoa-butter over the areas that are desquamating severely. 

The temperature can usually be controlled by the usual osteo- 
pathic methods; steady deep pressure apphed in the sub-occipital region 
for a few minutes, followed by relaxing the muscles of the back from the 
first to the eighth dorsal, by raising and spreading the ribs in the mid-dor- 
sal area, and by light inhibition over the solar plexus. The tepid enema 
will assist in lowering the temperature. If temperature is high and pa- 
tient is delirius and has other nervous sjanptoms the cold pack is useful. 
The ice cap may be used almost constantly in high fever. If glands are 
swollen treat by crowding the tissues toward the gland but never work 
upon the gland itself. 

If pain is felt in the ear immediate attention must be given it. Cor- 
rect any deviations of the atlas or other upper ceri-ical vertebrae, relax 
the deep muscles at the angle of the jaw, and relieve any impingements 
in the lower cer\dcal and upper dorsal regions. The ear should also be 
treated with copious boric solution irrigations, as hot as can be borne and 
at low pressure. The condition of the ear drum membrane must be 
watched daily and if there is bulging and congestion it is safer to punc- 
ture the drum under cocaine than to await spontaneous rupture. Use 
small amount of boric powder after rupturing. 

The heart must be examined daily. Vigorous treatment through 
the thoracic region is indicated, if cardiac symptoms appear, and the 
patient must be kept quiet and in bed. If heart seems feeble it may be 
well supported by the cold packs directly over the heart. 

Nephritis is most common in the second and third weeks of the 
illness, but may develop later. In all cases where any symptoms of ne- 
phritis appear, light or severe, the patient must be confined to bed 
for at least four weeks, and kept on a milk diet. All irritants must be 
absolutely avoided. Hot baths should be given twice daily to increase 
the sweat and the urinary functions, the bath lasting half an hour and 
the patient kept afterward between blankets. Treat thoroughly, daily, 
the splanchnic and renal areas, paying particular attention to the tissue 
conditions in the lower dorsal region. 

In the milder cases, the urine contains albumin and a few tube casts, 
very rarely blood, and edema is shght or transient. Though the patient 



The Practice of Osteopathy 437 

improves, he remains pale and there is a shght trace of albumin in the 
urine for months. If recovery does not take place, then chronic ne- 
phritis becomes established. 

In the more severe cases there may be a puffy appearance of the 
eye-lids, sHght edema of the feet, urine diminished in quantity, smoky, 
containing albumin and tube casts. The kidney symptoms dominate, 
dropsy persists and there may be effusion into the serous sacs. The 
condition may become chronic, the patient may succumb to uremia, 
but in the majority of cases recovery takes place. 

The nephritis may be hemorrhagic, in which the urine is suppressed 
or there may be a very small amount of bloody fluid laden with albumin 
and casts; constant vomiting and convulsions follow and the patient 
dies with symptoms of acute uremia. 

Other complications are arthritis, mahgnant endocarditis, severe 
toxic myocarditis and acute phlegmonous inflammation, the last three of 
which are usually fatal. Chorea is a fairly frequent nervous complica- 
tion. The mental symptoms are mania and melancholia. Progressive 
paralysis of the limbs with wasting, may simulate infantile paraylsis. 
The fever may persist after the eruption disappears and the child remain 
in a septic state (scarlatinal typhoid). 

Relapses are rare. Scarlatina may coexist with almost any other 
acute infection. It lowers the resistance of the body to disease and is 
often followed by other acute infections or by tuberculosis. Therefore 
the necessity of care during the entire convalescent stage. 

Measles 

(Rubeola; Morbilli) 

Definition. — Measles is an acute infectious, congatious, erythe- 
matous disease, occurring in epidemics, characterized by an initial coryza, 
bronchial catarrh and an eruption of a general maculo-papular type ; also 
by the presence of Koplik's buccal spots. 

Etiology. — Predisposing Influences: The chief predisposing 
factor in measles, as in all other contagious diseases, is a lowered resistance 
in which some structural or functional change has taken place that re- 
duces the functional activity of the body's inherent protective agencies. 
These predisposing factors may be classed under three heads, namely; 
(a) structural, (b) environmental, (c) dietetic. Under the first we find 
structural disturbances in the upper cervical area affecting the functional 
control of the nose, throat and head, as well affecting the thyroid and its 
internal secretions: structural disturbances in the upper and mid-dorsal 



438 The Practice of Osteopathy 

areas affecting the vasomotor control to the head, neck, and chest, there- 
by perverting nutrition to all these structures and rendering them more 
susceptible to the infective organisms; also the dorsal lesions disturb the 
functional integrety of the lungs and heart, with the result of disturbed 
respiration and circulation, both of which are vital factors in body re- 
sistance: we also find structural lesions in the lower dorsal region, affect- 
ing the function of the kidneys and their elimination and the function 
of the adrenals and their internal secretions. Under the second or en- 
vironmental, we have unsanitary and unhygienic conditions, exposure 
to sudden changes of temperature, wet clothing, fatigue, etc., all of which 
produce secondary structural lesions and the effects above mentioned. 
Under the third or dietetic classification, we have the errors of diet so 
common in children and adults as well; such as too much candies and 
other sugars, also too much starches, as well as over eating and unbal- 
anced diet. 

Measles prevails in all climates and attacks all races, the Negroes 
appealing to suffer more severely than the whites and to be more subject 
to complications. Outbreaks are more common in winter and spring, 
but occur at all seasons. The disease is particularly a children's dis- 
ease but adults may contract it if not protected by an attack in early 
Hfe, and with adults the disease frequently manifests the more aggra- 
vated forms. It is more common after puberty than scarlet fever. 

Exciting Cause. — While the disease is probably produced by a 
micro-organism, it has not yet been demonstrated. Inoculation experi- 
ments upon human beings have shown the presence of the infecting prin- 
ciple in the blood, in the tears, in the secretions of the nasal, pharyngeal 
and bronchial mucous membranes, and in the contents of vesicles occas- 
ionally present. Inoculation with the epitheHal scales thrown off at the 
end of the disease has been unsuccessful. Ordinarily the transmission 
of the disease takes place through the breath or the nasal and bronchial 
secretions. The disease may be carried by a third person or by fomites. 
The infecting principle is intensely active, but not so tenacious nor per- 
sistent as scarlet fever. Measles is communicable throughout its entire 
course from the earhest appearance of the coryza. The individual pre- 
disposition toward measles is apparently so general that few, upon expos- 
sure, escape it, though we have observed cases where children have been 
directly exposed and who were immediately thereafter put under osteo- 
pathic care and did not develope the disease. Second, or even third, at- 
tacks may occur at intervals of some years, but these are unusual. Spor- 



The Practice of Osteopathy 439 

adic cases do occur and are often the starting points for epidemics. Ex- 
tensive outbreaks occur at intervals of five or six years. 

The incubation period is from seven to eighteen days, usually about 
ten days. 

Symptoms. — Prodromes are common, usually consisting of loss 
of appetite, restless sleep, fretfulness, and often feverishness. There 
are three stages, (a) Invasion, (b) Eruption, (c) Desquamation. 

(a) Stage of Invasion. The prodromal symptoms are intensified. 
There is often chilHness but seldom distinct chills. The temperature 
rises, often reaching 102 to 104 degrees, upon the first and second day. It 
then falls one degree or more to rise again upon the appearance of the 
eruption. Nausea, vomiting and headache are often present. The 
tongue is furred. With these symptoms coryza has developed and is 
sometimes intense, often simulating severe influenza. Irritation and 
smarting of the eyehds, lachrymation, photophobia, persistent sneezing, 
running of the nose, sore thi'oat, discomfort in swallowing, hoarseness, 
and cough, at first of a croupy character, appear in rapid succession and 
with varying intensity. These initial catarrhal symptoms are character- 
istic and occur in the mildest cases in which chilliness, fever and the as- 
sociated signs of the reaction of the organism to general infection are 
not observed. The vessels of the conjunctivae are injected, the eye- 
lids swollen, the nasal mucosa tumid and reddened. The mucous mem- 
brane of the mouth and throat is erythematous, while upon the soft pal- 
ate and the roof of the mouth, and particularly upon the buccal mucous 
membrane, are to be seen pin head or spht-pea sized, circumscribed, 
round or irregularly shaped reddish blotches slightly or scarcely at all 
raised above the surrounding tissues, usually discrete, but sometimes con- 
fluent. This eruption also shows itself in the larynx and is undoubtedly 
the cause of the croupy cough and other throat sjTiiptoms. In a strong 
light there may be seen upon some of the spots on the mucous membrane 
of the cheeks and hps minute bright whitish, or bluish-white flecks which 
are called Koplik's Spots. These spots appear early and soon disap- 
pear, and as they are not found in any other disease they are of value in 
the early diagnosis of measles. The duration of this stage is usually three 
or four days; rarely it is shorter or it may be as long as a week. 

(b) Stage of Eruption. On about the fourth day the temperature 
again rises, increasing as the rash develops, often to 104 or 105 degrees 
and reaching its maximum about the sixth day when it usually falls by 
crisis; followed on the seventh or eighth day by normal temperature. 
The pulse rate increases with the fever, often reaching 140 or higher. 



440 The Practice of Osteopathy 

The eruption iisualty appears on the fourth day, and shows first about 
the hair line on the forehead, spreading to the face, chest, trunk and the 
arms and legs. The eruption is attended by itching and burning, and 
completely develops in from twelve to thirty-six hours, the catarrhal 
symptoms persisting during this time. During this time, in the more 
severe cases, delirium or stupor may be present, and the patient com- 
plains of sore throat and general discomfort, and is restless and wakeful. 
Usually upon the second or third day of the eruption, great and rapid 
amelioration of all these symptoms takes place and the fever falls to 
normal or sub-normal. When the eruption is fully developed the indi- 
vidual spots are irregularly circular or oval, and diiffer greatly in size, 
averaging about the size of a split pea. The eruption is unevenly set, 
but usually close together and sometimes confluent, especially on the 
face, buttocks, hands and feet. Frequently they take on a crescentic 
arrangement and the spots are circumscribed, the intervening skin being 
normal or slightly hyperemic. 

About the ninth day the rash begins to disappear, on the face first, 
then the neck and the rest of the body iu about the same order as the 
eruption appeared. The skin takes on a yellowish discoloration and the 
rash disappears in a bran-like desquamation which lasts several days 
to a week. In the beginning of the stage of eruption, and in many cases 
throughout its course, the skin is moist and often bathed in free per- 
spiration. At the height of the eruption the superficial lymphnodes of 
the neck, and elsewhere, are often slightly swollen and tender. 

(c) Stage of Desquamation. The fine branny scales of desquama- 
tion are often so fine as to be easily overlooked. This process occupies 
about a week. The catarrhal symptoms in uncompHcated cases gradu- 
ally disappear, so that, by the end of the second week from the initial 
coryza, convalescence is fully established. The cough frequently per- 
sists and is of a bronchial nature. Epitaxis is common at the height of 
the attack. Relapses of measles are extremely rare. Diarrhea is apt 
to occur at some time during the attack, without any particular signifi- 
cance. 

Varieties. — Atypical cases may occur but are not common. Thej^ 
are as follows: (1) Morbilli Papulosi, development of distinct papules, 
hard to the touch but not extending deeply into the skin. (2) M. 
Vesicular; a vesicular form. (3) M. Sine Exanthema, cases in which 
the eruption does not appear, but general symptoms and coryza are 
present. (4) M. Sine Exanthema, in which the mucous membranes 
are not involved. 



The Practice of Osteopathy 441 

Variations in constitutional symptoms. — (1) M. Afebriles, 
rare cases in which there is no rise of temperature. (2) M. Hemorrha- 
gica. This is the malignant form and in it the organism is unable to 
withstand the intensity of the infection and death takes place in the course 
of two or three days after sustained hyperpyrexia, profound adynamia, 
or hemorrhages into the skin and mucous membranes. These malig- 
nant forms are very rare in private practice, but they occasionally occur 
in asylums and in the fierce epidemics of camps, and were common in 
the first outbreaks among the natives of the Fiji Islands, where measles 
prevailed as a scourge. Death may occur before the rash appears or a 
few papules may show themselves upon the forehead and wrists. This 
is also known as black measles, and it is characterized by convulsions, 
delirium and coma, petechiae, bleeding from the mucous surfaces and 
profound constitutional depression. The patient is rapidly exhausted, 
the pulse frequent and thready, the skin pale and cold, and death oc- 
curs. (3) Adynamic measles is a serious type in which the symptoms are 
grave from the onset but without hemorrhages and a t3^phoid status 
is early present. 

Complications. — In the absence of complications, measles is com- 
paratively a benign disease, but these complications are frequently enough 
present to place measles among the more serious diseases of childhood. 
The ordinarj^ complications are due to the extension or intensification 
of the catarrhal processes peculiar to the disease. 

(1) Otitis media is quite common, and msiy result in perforation 
of the tympanic membrane and permanent impairment of the hearing; 
or lead to sinus thrombosis, meningitis, or abscess of the brain. (2) 
Bronchopneumonia is the most common complication. (3) Purulent 
conjunctivitis may occur and in neglected cases infiltration and ulcera- 
tion of the cornea. (4) Catarrhal laryngitis is a frequent complication. 

(5) Pseudo-membranous type is very uncommon but very dangerous. 

(6) Edema of the glottis is not common but does occur. (7) Diphtheria 
is much less common in measles than in scarlet fever. The high death 
rate of measles is due to the bronchopneumonia compUcation in which 
the lesions become extensive, the symptoms become urgent and a large 
proportion of these cases die. (8) Acute enterocolitis is a frequent and 
s(M'ious complication. (9) Gangrenous stomatitis occurs in young and 
debilitated children, and in girls gangrene of the pudenda occur during 
convalescence with greater frequenc}^ than in other infectiouss diseases. 

Sequelae. — The more common sequelae are chronic local infiam- 



I 



442 The Practice of Osteopathy 

mations, conjunctivitis, otitis, nasal catarrh, laryngitis, and bronchitis. 
Tuberculosis is a common sequel. 

Diagnosis. — During an epidemic, coryza, persistent sneezing and 
fever are suspicious. The appearance of the eruption on the third or 
fourth day upon the mucous membrane of the mouth and throat, and 
Koplik's spots are positive. 

Measles is often confused with 1. Rubella or German measles, 
2. Variola, 3. Typhus Fever and 4. Scarlet Fever, which see. Oc- 
casionally drug exanttiems are confused with measles. These may 
be caused by salicylates, antipyrin, quinine, turpentine or copaiba. 
These rashes are not accompanied by fever or throat symptoms unless 
they have been given to allay these very conditions. 

Treatment. — Measles is so often a serious disease that it should 
not be attended with carelessness as it so often is, but the best of care 
and attention given. Parents should be informed of the danger of com- 
phcations and of the absolute necessity of proper care and attention. 

As soon as a susceptible individual is exposed to the measles, he 
should be immediately isolated, watched and corrections made of any 
dietetic errors, unsanitary conditions or structural lesions that may exist. 
He should be protected from sudden atmospheric changes and carefully 
watched for the first symptoms of the prodromal coryza. 

On the appearance of the prodromal, or invasion symptoms the 
patient should be put to bed in an isolated, well-ventilated room of as 
nearly constant temperature as is possible, from which all hangings, rugs 
and unnecessary funiture have been removed. The windows must be 
shaded to protect the eyes from direct or strong light, and any artificial 
lights in the room must also be well shaded. 

The cases can usually be easily handled by careful, well-directed 
osteopathic treatments. In the manipulative treatment we must pay 
especial attention to the muscular and other soft tissue conditions in the 
suboccipital region, over the transverse processes of the upper four or 
five cervical vertebrae, under the angle of the lower maxilla and the 
lateral cervical tissues to remove any obstructions to the circulation and 
nerve control of the head and throat; see that the muscles in the lower 
cervical and upper dorsal areas are kept well relaxed, and articulation of 
these vertebrae, the upper three ribs and the clavicles are kept free; 
remove all lesions in the mid dorsal area, whether muscular or otherwise, 
to prevent involvement of the lungs or heart, and' to keep up function 
of the respiratory and circulatory systems ; treat and keep normal the tis- 
sues and the articulations at the kidney and adrenal center, 11th and 12th 



The Practice of Osteopathy 443 

dorsal; raise the ribs and keep them freely movable, this especially for 
the bronchial cough. Painful manipulations should be avoided and are 
not necessary. Dr. Still said, "The arms must be raised and the axillary 
region freed and kept so." During the acute stage two or three treat- 
ments per day are advisable. Do not treat severely or to cause discom- 
fort to the patient. Best results are obtained in the gentle, but thor- 
ough, treatments. 

In the beginning of the case have the bowels cleansed with an enema, 
and then careful attention must be constantly given to the bowels and 
kidneys. The bowels can be kept open by manipulations and diet. 
The diet should be light and easily digested; during the fever it is best 
to withhold all food but give plenty of water. Follow fast with fruit 
juices and then the Kght diet. 

The temperature is usually controlled by treatment, but if it remains 
high for some time and if the physician cannot reach the patient, the 
nurse should be directed to give a tepid sponge bath of ten to twenty 
minutes duration, and repeated at intervals of two or three hours. Also 
the tepid enema will often reduce the temperature. 

For the itching of the skin, a tepid bath with water at 100 degrees 
given twice daily should be used, the patient dried carefully, and an appH- 
cation of oHve oil, cold cream, liquid albolene, or a two per cent menthol 
salve, rubbed over the entire body will give rehef . 

The cough is best reUeved by thorough treatment of the anterior 
thoracic regions and the correction of any upper rib or clavicular lesions. 
Keeping the air of the room moist with vapor is agreeable to the mucous 
membranes. The dropping of a few drops of eucalyptus oil in the boihng 
water produces a very soothing vapor. 

If the eyes are much involved, they should be bathed every hour 
or two with a three per cent solution of boric acid, using cotton which is 
immediately destroyed after use. Dark glasses in a well ventilated room 
is better than an unaired darkened room. 

The nose and mouth should be carefully cleansed at regular inter- 
vals and the cloths burned. The throat should be carefully examined 
daily at first, and at least every other day later, until the case is discharg- 
ed. The conditions of the lungs must be observed by daily examinations, 
and the lung and bronchial areas should be daily treated to prevent the 
possibility of respiratory involvement. 

If rash is slow in appearing and the temperature is high, a hot l)ath 
(105 to 110 degrees) for three to five minutes will often bring out the 
rash and relieve the more serious symptoms. During convalescence the 



444 The Practice of Osteopathy 

patient must be protected against cold. Recovery is hastened by the 
continuation of treatment during convalescence and treatment given 
should be indicated by the symptoms present. 

Prognosis. — Practically all uncompHcated cases recover. In the 
hemorrhagic and adj^namic types, the majority succumb. One attack 
usually confers immunity. Sequelae are frequent under the "old school" 
treatment, but are infrequent under careful, conscientious osteopathic 
treatment and careful nursing. 

"In and of itself measles is usually not particularly serious, but the 
after-effects are so far-reaching and so serious that students of the his- 
tory of medicine rank measles third among infectious diseases for causing 
death. During recovery from measles the patient stands in special 
danger from pneumonia, and pneumonia following measles is more dan- 
gerous than uncomplicated pneumonia. There is a considerable length 
of time during which he is particularly susceptible to tubercular infection. 
This is so often insidious, and its evidences are so obscure, that by the" 
time the disease has fully developed, one may have forgotten the mild 
attack of measles which really paved the way for the serious malady. " 
— C. A. Whiting. 

Rubella 

(German Measles; Rubeola notha; Rotheln; Epidemic Roseola) 
Definition. — A specific acute, contagious, infectious, eruptive dis- 
ease, characterized by a diffuse maculopapular eruption and swelKng of 
the superficial Ijmiphatic glands. It is attended by a mild fever, suffused 
eyes, mild cough, slight sore throat but no catarrh, a macular rose-red 
eruption of the throat accompanied by the swelHng of the cervical Ijonph 
glands and by a rose-red eruption of irregular size and shape appearing 
on the fii'st day of the disease. 

Rubella, in some ways, resembles scarlet fever and also measles 
and was at one time considered a hybrid of the two. It is now known 
to be an independent disease. 

Etiology. — The exciting cause, or the infective principle, has not 
yet been discovered. The disease is probably carried by fomites, is read- 
ily transmissable, attacks children especially, and usually occurs in epi- 
demics, though sporadic cases are frequently found. The epidemics 
usually occur at intervals with several years intervening, during which 
time there are comparatively few cases. Persons of all ages are suscepti- 
ble unless having acquired an immunity through an attack of the disease 
at some former time. Rubella does not confer immunity against any 



The Peactice of Osteopathy 445 

other disease, as scarlet fever or measles, nor do these diseases confer im- 
munity against rubella. One attack of rubella confers immunity against 
any succeeding attacks. 

The incubation period is from five to twenty-one days and is without 
symptoms. 

The predisposing factors are the same as in measles or other infec- 
tious or contagious diseases. 

Symptoms. — Invasion Period. This stage is usually of very 
short duration, lasting from a few hours to perhaps two days. The 
initial symptoms are usually mild, being a sudden chilliness, but not 
chills; mild fever of about 100 degrees; a shght headache; mild sore throat; 
swollen cervical and post auricular lymphatic glands; Mttle or no coryza; 
sometimes shght pains in the back and legs; and the macular rose-red 
eruption in the throat which is constantly present. Often the initial 
symptoms are so mild that the presence of a disease is not recognized 
until the eruption appears, which usually occurs on the first day and rare- 
ly not until the fourth day. 

Eruption Period. — The rash, which consists of round or oval 
reddish spots about the size of a split pea, mostly discrete, but sometimes 
confluent, and surrounded by areas of hyperemic skin, usually shows 
first upon the face and follows a wavehke progression over the bodj^ and 
Hmbs. The rash usually begins to fade upon the face before it has ap- 
peared upon the last affected areas, and usually remains in one region from 
a few hours to a half day. It extends over the entire body in from twenty- 
four to thirty hours. Occasionally the skin is so hyperemic in exten- 
sive tracts that the rash more resembles scarlet fever rather than measles. 
The crescentic arrangement of the papules usually seen in measles can 
not be made out in rubella. In the course of two or th]-ee days the rash 
disappears with very fine desquamation, leaving a faint pigmentation, 
which remains for a short time. Shght etching usually accompanies 
the rash. 

Relapses are rare and comphcations infrequent. There are no special 
sequelae, but albuminuria, bronchitis and pneumonia have been noted. 
Although one attack usually confers immunity, second attacks have been 
reported, which may have been real second attacks or the first attack 
may have been an error in diagnosis. 

Diagnosis. — Early or sporadic cases may present great difficulty 
in diagnosis, but when an epidemic is present diagnosis becomes much 
easier. The direct diagnosis of the disease rests upon the very mild na- 
ture of the disease, its short initial onset, the character of the eruptions 



446 . The Practice of Osteopathy 

and the early enlargement of the glands with the absence of severe throat 
symptoms and coryza. 

Rubella is frequently mistaken for mild cases of measles or scarlet 
fever. Unlike measles, it does not have the prominent catarrhal symp- 
toms, the higher fever, the crescentic grouping of the eruption and 
Koplik's sign. In measles the adenitis is not so severe as in rubella, 
and especially are the sub-occipital and post-auricular glands involved in 
rubella. Scarlet fever has a very sudden onset with severe symptoms, 
a very sore throat, the characteristic tongue and the pecuHar rash, all of 
which are decidedly different from rubella. In the latter stages the 
character of the desquamation is also a distinguishing feature. 

Treatment. — Patient should be kept in a properly heated and 
well ventilated room, being careful that no draughts chill the patient, 
and should remain in bed for at least two days. Patient should be iso- 
lated. Treatment should be directed to the upper cervical, mid-dorsal 
and lower dorsal areas to keep normal the function of the internal secret- 
ing mechanism, and to normalize and keep normal the respiratory and 
circulatory systems. Treat carefully to upper lymphatics, working 
around the enlarged glands and not directly over them. Watch the 
excretory functions and keep them active by judicious measures. If 
annoying itching occurs, the hot bath followed by being wrapped in a 
soft warm blanket will usually relieve. Daily tepid sponging should be 
given and if hot bath does not relieve itching an application of olive oil or 
cold cream will often relieve. Diet should be reduced and regulated ac- 
cording to age of patient and severity of the case. Usually the above 
is all that is indicated, but if more severe symptoms present themselves 
vary your treatment according to the symptoms present. 

Prognosis. — Recovery is the general rule. Relapses sometimes 
occur, and are usually much more severe than the initial attack. The 
symptoms are often more severe in adults than in children. Like measles, 
this disease seems to lower resistance to other infections, and therefore 
especial care should be taken to protect the patient from exposure to other 
diseases for some time after recovery from rubella. See that the pa- 
tient is built ap constitutionally after recovery by plenty of fresh air, 
suitable exercises and good food. 

Varicella 

(Chicken Pox) 
Definition. — ^Chicken pox is an acute, specific, contagious, slightly 
febrile, eruptive disease, usually of childhood, affecting the whole or- 



The Practice of Osteopathy 447 

ganism through the blood. It is an epidemic disease that spreads rapid- 
ly, is highly contagious but not inoculable, and confers immunity. 

History. — Varicella was first recognized about 1553 and was dis- 
tinguished from smallpox by Trousseau. 

Etiology. — The agent that causes the disease is not known; the dis- 
ease usually affects children under ten years of age, but does occasion- 
ally attack adults. It bears no relation to variola, except the very 
shghtly similar eruption. It is transferred by direct personal contact, 
by the air or by a third person. It is infective from the first symptoms 
until all the crusts have disappeared. Although the disease usually oc- 
curs in epidemics, frequently we see sporadic cases. 

As in all other contagious or infectious diseases the predisposing 
causative factors are those conditions which lower the resistive powers 
of the body, such as fatigue, improper diet, exposure to sudden tempera- 
ture changes and imperfect ehmination of the bodj^ wastes. The struc- 
tural lesions found as predisposing factors are contractured muscles of 
the neck and behind the jaw, and muscular and interosseous lesions of 
the upper cervical, mid-dorsal and dorso-lumbar areas, also of the clav- 
icle and upper ribs. 

Symptoms and Diagnosis. — There are three stages to the disease: 
(1) Incubation, (2) Prodromal, (3) Eruptive. 

1. Incubation Period. — This period lasts about fourteen days 
though it may vary from seven to seventeen days. During this period 
there is practically no symptomatology except perhaps the last two or 
three days, when the child shows evidence of a little excitabihty and irri- 
tabihty. Often on the day before the first noticeable symptoms the child 
appears even more active than usual. 

2. Prodromal Stage. — Prodromal symptoms are not common and 
usually last but about twenty-four hours. The first noticeable symptom 
is the irritabiHty of the patient, which is followed by a temperature, 
usually 99° to 101°, which temperature persists during the course of the 
disease. There are sometimes thirst, anorexia, constipation, seldom 
vomiting, and a furred tongue. Some cases have been observed to have 
the following as prodromal symptoms, but these we beheve are usually 
due to concurrent conditions that exist at the time of the infection: 
delirium, convulsions, angina, conjunctivitis, dysphagia, bloody vomit- 
ing and stools, and an initial erythema, usually scarlatiniform. 

3. Eruptive Stage. — The eruption comes within twenty-four hours 
and is often the first symptom that is noticed. It appears first as hyper- 
cmic macules and then rose-colored papular spots, somewhat compar- 



448 The Practice of Osteopathy 

able to the typhoid roseobie and not hard. These papules rapidly be- 
come raised, flattened, ovoid, pin-head to pea-sized vesicles containing 
a fluid at first watery and then pearly. They disappear on pressure. 
The vesicles mature within twenty-four hours, are very superficial, and 
leave a shght areola about them, which is not inflammatory as in small- 
pox. The eruption appears first on the chest and then on the neck, 
face, scalp, and then trunk and Hmbs in the order named. The erup- 
tion is most abundant upon the back, and over the entire body they may 
number anywhere from eight to many hundred and are usually scattered. 

The vesicles are not umbilicated, but some may have slightly de- 
pressed centers, are discrete, and appear in successive crops which re- 
(juire from three to six days to complete. Pustulation and hemorrhage 
into the vesicle rarely occur. On the third or fourth day yellowish- 
brown crusts form and gradually disappear. Scars may result from 
scratching or infection. By the fifth day we may find all stages of the 
eruption because of the appearance of the successive crops. There may 
be an efflorescence upon the mucous membrane of the oral cavity and of 
the pharynx causing slight difficulty in deglutition. 

The itching may be more or less intense. As stratching may cause 
pitting it should be guarded against. The fever which is usually slight 
may persist during the entire eruptive stage, but if it is high and persists 
as high temperature it suggests compHcations. Muscular tension of the 
cervical muscles, especially those in front, and around the angle of the 
inferior maxilla are usually found, and often the clavicles are bound down, 
and relation of ribs is disturbed. Ulceration sometimes follows scratch- 
ing, and even gangrene may appear around the vesicles in debilitated 
children, especially those who are tubercular or congenitally syphil- 
itic. It is apt to be fatal in these cases. Complications of tubular 
nephritis, which occurs within two weeks; cardiac hypertrophy; uremia; 
otitis media; and bronchial affections, are sometimes met with. 

Treatment. — Isolate patient so as not to come in contact with 
other children. The younger children should be put to bed until the 
crusts have formed; older children may be allowed to be up around the 
room if their cases are light. Pay particular attention to the muscular 
lesions of the neck, lower maxilla, mid-dorsal and dorso-lumbar regions, 
keeping them relaxed by gentle relaxing treatments. A general systemic 
treatment is soothing and helps to prevent comphcations. 

"Be very careful and very thorough in your neck adjustments. 
Loosen the atlas and axis and draw forward the inferior maxilla from its 
pressure upon the vessels and nerves back of its angle. Draw the hyoid 



The Practice of Osteopathy 449 

bone forward and secure good circulation of blood throughout the entire 
cervical area. " — A. T. Still. 

Give treatment at the 4th and 5th dorsals to stimulate the super- 
ficial circulation and thus increase elimination through the eruption as 
well as the sweat glands. Remember the eruption is the expression of the 
body's attempt to eliminate the toxins within. 

Keep the bowels active by splanchnic and abdominal manipula- 
tions and by laxative diet. . If bowels are persistently inactive use ene- 
mata. Diet should be bland and easily digested. During fever, diet 
should be liquid or better restricted, giving only water in abundance. 

During the eruptive stage do not use tub baths. Daily tepid sponges 
with either plain water or boric acid solution answers both as an anti- 
septic wash and bathing. After the daily sponging, and as often as 
necessary to control itching, anoint with a 10% boric acid ointment or 
with carboHzed vasehne. If scratching can not be controlled, the hands 
should be tied in musHn bags. As in smallpox the ultra-violet rays seem 
to irritate the eruptions and to increase the tendency to scarring, there- 
fore the windows and lights should be screened with a dull red material. 

Prognosis. — Invariably favorable unless compHcations set in, 
which is seldom. Recurrences are very rare. 

Prophylaxis. — The child should be kept in quarantine for three 
weeks or until the skin is entirely clean. 

Epidemic Parotitis 

(Mumps; Epidemic Parotiditis) 

Definition. — Mumps is an acute, infectious, contagious disease, 
occurring in limited epidemics, and characterized by inflammation of the 
salivary glands, particularly the parotid, swelling sHght fever and pain 
over the involved glands. There is special Habilitj^ to orchitis or to 
mastitis. 

Etiology. — Predisposing Factors: Mumps is peculiarly a disease 
of childhood and adolescence, not being common in infancy or after the 
twentieth year. It affects boys nearly t\yice as often as girls. Mandi- 
bular and upper cervical lesions, both of the interosseous and soft tissue 
types, are undoubtedly potent presisposing factors, as they obstruct 
and interfere with nerve and circulatory function to the glands affected. 
Also any condition which lowers the child's resistance to infections makes 
them more susceptible to this disease than to any other, these conditions 
being fatigue, exposure to dampness and sudden weather changes, dietetic 
errors, etc. The cases are more numerous in the spring and autumn 



450 The Practice of Osteopathy 

seasons. Extensive epidemics are infrequent, but do occur in reforma- 
tory institutions and children's homes. It is much more wide-spread in 
large cities than in the country or villages. 

Exciting Cause; The specific cause has not been demonstrated. 
The disease is usually transmitted by direct contact, but there are in- 
stances where it has been transmitted by a third party or by fomites. 
There are two views as to the mode of infection ; the first being that the 
active principle travels along the course of the salivary ducts from the 
mouth to the glands, probably most often through the duct of Stenson 
to the parotid gland. This is the most generally accepted theory. The 
second is that the infection is a general one to which certain structures 
are more susceptible, principally the sahvarj^ glands, and the parotid 
in particular. 

Symptoms. — The period of incubation is from fourteen to twenty- 
one days. Prodromes are usually absent, though in the more severe 
cases constitutional disturbances, with chilhness, vomiting and mild 
fever may precede the local inflammation. In the milder cases the local 
swelling may be the first manifestation of the disease. The temperature 
is usually moderate but may rise to 103 or 104 degrees in the more severe 
cases. The left side is more often affected than the right. The disease 
is characterized by a feeHng of tension with soreness just below the ear. 
Soon a slight swelhng may be observed directly under the ear and in the 
course of forty-eight hours it reaches its maximum size. The parotid 
gland becomes greatly enlarged and the adjacent tissues of the neck and 
face become tense and edematous. The skin becomes hard and glossy 
and usually white in color because of the obstruction to the circulation 
from pressure. The swelling is between the angle of the jaw and the 
mastoid process, pushing the ear upward and its lobule is pushed sharply 
outward. In the majority of cases the other side becomes affected in 
two or three days, but sometimes the spread of the disease to the other 
side is delayed for several days, and occasionally the other side escapes 
the infection. Frequently the swelhng of the other side is so sUght 
that it is only recognized by the closest scrutiny. Infrequently the sub- 
maxillary glands become affected without involving the parotid glands, 
but these cases are rather rare. 

The patient is usually unable to open the mouth without considera- 
ble pain; acids, and rarely sweets, produce spasms of the jaw muscles; 
speech and even deglutition are difficult; the salivary secretions are usu- 
ally increased but quite frequently they are decreased. The breath 
is foul and the tongue is furred. The mucous membrane of the cheek 
and pharynx are reddened and there may be a slight angina. 



The Practice of Osteopathy 451 

The spine shows subluxations of the upper cervical area, particularly 
of the atlas and axis, also upper rib lesions and upper dorsal lesions are 
frequently found. The lesions of the second and third dorsal, and their 
ribs, are most frequently found when the submaxillary gland is involved. 

The symptoms persist from six to fourteen days, when the swelKng 
disappears and the patient regains normal health. Orchitis occurs in 
about one-third of the cases after puberty. In infancy and childhood it 
is extremely rare. Usually one testicle is involved, and is characterized 
by weight, swelling and pain in the scrotum. The testicle may become 
greatly enlarged when the pain becomes intense. Atrophy may result 
and if both testicles are affected the loss of reproductive abihty may re- 
sult. In females, usually after puberty, the breasts may become enlarged 
and tender, pain and tenderness of one or both ovaries, hematoma of 
the labia, or a vulvovaginal discharge may occur. • However these com- 
plications are very rare. As a rule the patient is not very sick and relap- 
ses are very uncommon. The attack confers immunity which is practic- 
ally permanent. 

Diagnosis. — Under ordinary conditions, especially during an epi- 
demic, the diagnosis of mumps is very easy. The swelHng in front of 
and below the ear, with the displacement of the lobule outward is quite 
indicative of mumps. The relative rapidity with which the swelhng ap- 
pears, develops and subsides is characteristic of mumps. In acute 
cervical adenitis the swelUng is below the angle of the jaw and does not 
at any time correspond with the outhne of the parotid gland. In Hodg- 
kin's disease, which is a chronic affection of the lymphatic glands, the 
salivary glands are not involved. 

Treatment. — The patient should be kept away from other children, 
and should remain in a well lighted, well ventilated room of even tempera- 
ture, and if the temperature is high or moderately high he should be kept 
in bed. 

The correction of all interosseous lesions is indicated, especially of 
the upper cervical area, though the second and third dorsal should be 
given attention because of the influence of these dorsal nerves upon the 
submaxillary glands. Also correct upper rib lesions that may exist. 
As mumps is an infective disease the channels of ehmination should be 
watched and stimulated. Build up the body resistance by treatment at 
the mid dorsal area to affect circulation and respiration ; and lower dorsal 
area to affect kidney and adrenal function. Watch the bowels and keep 
this avenue of elimination functioning freely, using enemata if necessary. 

The diet should bo liquid, of fruit juices, thin gruels, milk and plenty 



452 The Practice of Osteopathy 

of water. Tepid sponging allays the fever and restlessness. Relaxation 
of the deep muscles of the neck and shoulders will do much to make the 
patient comfortable, also the muscles under the angle of the jaw. A 
very gentle relaxing of the tissues ai'ound the gland itself, by crowding 
them toward the gland, assists in relieving the tension by securing a better 
venous and lymphatic drainage. 

Hot applications to the swollen glands will give a considerable 
rehef ; these may consist of hot fomentations, hot salt bag, electric heating 
pad, hot water bottle, etc. The mouth is kept in good condition by the 
use of a mild antiseptic mouth wash. 

Orchitis should not occur if the boy is kept warm and in bed. If 
it does occur the best treatment is relaxation of the lower dorsal and upper 
lumbar spinal muscles, rest in bed, support and protection of the scrotum 
with cotton wool, cold applications, correction of any bony lesions affect- 
ing the pelvic viscera. 

If mastitis occurs, rib lesions will be found and should be corrected, 
as they are probably the predisposing factor to this comphcation. Treat- 
ment would consist of correction of these lesions, if it can be done without 
irritating the inflamed glands. The manipulation of the surrounding 
tissues, with gentle crowding of the normal tissues toward the inflamed 
glands, without exerting any pressure on the gland itself, is helpful and 
comforting. Free tissues back to the axillary lymphatics. 

Prognosis. — The outcome is usually favorable. In the rare fatal 
cases, meningitis is the usual cause of death. Under osteopathic care the 
duration of the swelhng, fever and pain is usually greatly lessened. 

Quarantine of twenty-four days is necessary. 

Whooping Cougli 

(Pertussis; tussis convulsiva) 

Definition. — It is a specific, epidemic, infectious, contagious dis- 
ease affecting the respiratory organs, characterized by a cyclic course, 
a severe convulsive cough, paroxysmal, with the characteristic "whoop." 

Etiology. — It usually occurs in children, most frequently during 
the fourth year, and extremely seldom after the twentieth year. It ap- 
pears to be slightly more frequent among girls, and most cases occur in 
March and April. Pertussis is highly contagious, being carried by di- 
rect contact and by fomites. The Bordet and Gengou bacillus is the 
specific cause. This is found in the sputum most abundantly during 
the first week, the most infectious period, and becomes gradually less. 
One attack usually confers immunity. 



The Practice of Osteopathy 453 

The incubation period is from seven to ten days. The patient may 
be considered non-infectious five weeks after the first whoop. 

Lesions of the cervical and upper dorsal vertebrae and of the first, 
second and third ribs, affecting the vagi, the phrenic, the sympathetic, 
the recurrent laryngeal or the vasomotor nerves predispose to the dis- 
ease. 

The bacteria were found by Mallory and Horner to be characteris- 
tically between the cilia of the trachea and the bronchi. They interfere, 
mechanically, with the movements of the cilia, preventing the normal 
removal of secretions. 

Symptoms. — The disease is divided into three stages: 1. The ca- 
tarrhal stage, which lasts one to two weeks; 2, the spasmodic stage, three 
to six weeks; 3, the dechning stage, three weeks. 

The Catarrhal Stage: Characterized by headache, photophobia, 
conjunctivitis, coryza and a cough which becomes drier and harder to- 
ward the end of this stage. Often the invasion is insidious and sometimes 
well marked with a temperature of 100° to 102°. Frequently this stage 
cannot be diiferentiated from a "hard cold," except toward the end of 
the stage when the cough becomes worse instead of better, and the child 
will seek some support to steady itself during the coughing paroxysm. 
Also the eyes will water freely during the coughing spell and the child 
will not be able to "get his breath" between coughs, but will have a 
number of coughs without inhahng. 

One to two weeks. 

The Spasmodic Stage: This stage dates from the "first whoop." 
The fever now usually ceases, unless there are complications. The 
cough becomes paroxysmal, consisting of a succession of fifteen or more 
short, rapid expiratory puffs with no intervening inspirations, immed- 
iately followed by a deep, loud inspiration, which is the characteristic 
" whoop, " and is due to the partial closure of the glottis. Each paroxysm 
is composed of three or more such spells, the last one often followed by 
the expectoration of a small plug of mucus or by vomiting. During the 
paroxysm the facies presents a swollen, dusky appearance, eyeballs pro- 
truding, eyes reddened, and puffy, pinkish lids. The child is well ex- 
cept for the paroxysm, which has an aura, tickhng in the larynx, thoracic 
constriction, a creeping sensation, when the child attempts to brace 
himself, or runs in terror for support. The "whoop" is a deep, singing 
or whisthng inspiration which is absolutely characteristic. During the 
cough the child's body is bent forward and he is perfectly helpless, often 
passing ui-ino and feces involuntarily. Cyanosis often occurs from the 
strain. 



454 The Practice of Osteopathy 

After the attack patient regains control of himself, the respiration 
is fast, and there is fatigue, sweating and often pain in the abdomen from 
the strain of coughing. During the severe cough petechise of the fore- 
head, ecchymosis of the conjunctivae, epistaxis, bleeding of the external 
auditory meatus or from the frenum of the tongue may occur. Ulcer 
of the frenum of the tongue is quite common. The parosyxms vary from 
four to a great many per day, averaging about twenty. 

Three to six weeks, usually four weeks. 

The Terminal or Declining Stage: This stage is longer in pro- 
portion in the mild cases. The paroxysms occur at longer intervals, are 
of shorter duration and of less intensity, the catarrhal symptoms are more 
marked, the expectoration becomes thinner, fluid, mucopurulent, and 
looser. The "habit cough" may follow. It is during this stage that 
complications are most hkely to occur, therefore it is the most danger- 
ous. 

Complications. — Catarrhal inflammations are common in the ini- 
tial stage. Bronchopneumonia is the most frequent and severe 
complication. Lobar pneumonia, exudative pleurisy, endocarditis, 
pericarditis, meningitis and nephritis are infrequent complications. 
Spasms of the glottife in nervous or scrofulous children is largely noc- 
turnal, and may cause death from asphyxia even in the lightest cases. 
Hemorrhages may occur in the skin, conjunctivae, nose, throat, ears or 
cerebrum. The writer knows of one case where death was sudden from 
a cerebral hemorrhage in an apparently mild case. Other complica- 
tions are cardiac dilatation, emphysema, bronchiectasis, pneumothorax, 
aneurysm hernias, muscular ruptures, and visceral prolapses. 

Spasmodic cough from diseased l^ronchial glands very closely re- 
sembles whooping cough. Barthez and Sannee give the following differ- 
entiation: 

Whooping Cough vs Enlarged Glands 

1. Contagious, epidemic. Isolated, not contagious. 

2. Three periods, 2nd parosyxmal. No distinct periods. 

3. Paroxysmal cough with whoop. Paroxysms without whoop, expec- 
vomiting, viscid expectoration. toration or vomiting. 

4. Respiratory sounds normal. Signs of enlarged glands sometimes 

present. 

5. Respiration normal in interval; Asthma in some cases, febrile move- 
apyrexia if simple. ments, sweats, wasting, etc. 

6. Voice natural. Voice sometimes changed. 

7. Acute. Chronic. 



The Practice of Osteopathy 455 

Treatment. — Isolation of patient in well-ventilated, sunny room 
vhere there is plenty of fresh air day and night is essential. Children 
3xposed to infection should be disinfected and isolated for three weeks, 
as the disease can not be diagnosed during the catarrhal stage. If case 
is at all severe, patient should be put to bed. 

Cases receiving early treatment are sometimes aborted. Treat- 
ment of the whole respiratory tract with correction of vertebral and rib 
lesions, and relaxation of the contracted muscles should be given. Treat- 
ments for the first few days should be at least twice per day. Pay es- 
pecial attention to the vagi and phrenic nerves. Lesions of the first 
and second ribs will affect the recurrent laryngeal nerves which will 
aggravate the cough. The muscles of the shoulder girdle are always 
very tense and should be kept well relaxed, as should the subscapular 
muscles. Frequently after treatment the child will have a coughing 
spasm and raise large quantities of mucus, after which there will be no 
more spasms for several hours. 

Children who play and live out of doors get along best. To sup- 
port the diaphragm and abdominal muscles from the strain of cough- 
ing a musHn bandage tightly pinned about the trunk is very valuable, a 
pad being placed over the stomach under the bandage. In a very 
young child instruct the nurse to strongly flex thighs on abdomen during 
the severe coughing. Inhalations of steam from water with a very few 
drops of eucalyptus oil in it often relieves the first tickling sensations. 

If cyanotic symptoms appear they may be relieved by raising the 
ribs, especially those over the heart; by relaxing the subscapular mus- 
cles; and by supporting the heart by application of cold cloth over the 
heart. Elevating the abdominal viscera and diaphragm is, also, of dis- 
tinct benefit. 

The diet should be nutritious and easily digested, restricted to 
liquids during the fever. The child should be warmly clad and pro- 
tected from drafts. The excretory systems should be kept active by 
plenty of water drinking and by diet. Treatment should be continued 
during the terminal stage to prevent the possible complications. Irri- 
tants, as beef-tea, stimulants, dry bread, cookies and overfeeding, pro- 
voke coughing and vomiting. Food should be given at frequent intervals 
in concentrated form — gruels, milk with lime water, zwieback in milk, 
eggs, inoat-juicc, etc. Older patients tolerate more solid food. 

Prognosis. — With the complications, this is the most fatal of the 
acute infections under five years of age. Infants and little children 
should receive special care. Ordinary uncomplicated cases are favor- 



456 The Practice of Osteopathy 

able for recovery. The prognosis depends upon the age and strength 
of the patient, the severity and number of the paroxysms, and the pres- 
ence or absence of comphcations. No recurrence is to be. expected. 

Death is due to spasm of the glottis or to extensive subdural hemor- 
rhage, occurring chiefly in the children of the poor and in delicate in- 
fants. 

Prophylaxis consists of isolation, disinfection of sputum and final 
fumigation of the premises. Children should be protected from ex- 
posure to infection from whooping cough. It must be realized that it is 
a very serious disease. 



The Peactice of Osteopathy 457 

CONSTITUTIONAL DISEASES 
Rheumatic Fever 

(Inflammatory Rheumatism) 

Definition. — An acute, febrile, non-contagious disease; it is in- 
fectious, although there is some controversy as to its exact nature; char- 
acterized by a multiple arthritis and a tendency to involve the heart. 

Osteopathic Etiology and Pathology. — The prevailing thought 
is that the disease is an infection due to a diplococcus. This micro- 
organism is called by others micrococcus rheumaticus and streptococcus 
rheumaticus. 

"Rheumatic fever occurs most frequently in the temperate zone, 
among people who Hve under conditions which are unhealthful and which 
especially induce focal infection. It is most prevalent in the young and 
in the more exposed male of all ages. The excess of lymphoid tissue in 
the pharynx and nose of the young explains the frequency of the inci- 
dence of the focal infection and the subsequent rheumatism. The fre- 
quent association of the onset of rheumatic fever with lowering of the 
body temperature by exposure to cold and a wetting is explained by the 
increased specific virulency of the bacterial cause acquired by a low 
temperature and the coincident lessened resistance of the patient due to 
the exposure. The frequent absence of evidence of acute focal infec- 
tion at the onset of the systemic disease is not an evidence that no focus 
exists. The latent chronic streptococcus infection of tonsilUtis, pyorrhea 
alveolaris, sinuitis, etc., may suddenly acquire increased virulence and 
specific pathogenic affinity with varying degrees of focal tissue reaction. 
This transmutation of type and pathogenicity certainly occurs in the 
focus of infection. The removal of the tonsils and other sites of focal 
infection has been followed by complete recovery of prolonged, sub- 
acute and chronic types of arthritis and has unquestionably prevented 
recurrent attacks of rheumatic fever to which the susceptibility is in- 
creased by one or more attacks. The occurrence of rheumatic fever 
after the removal of an apparent focus may be due to secondary systemic 
latent foci in lymph nodes proximal to joints, in the neck or elsewhere. 
The streptococci of these secondary foci may take on new virulence 
and specific pathogenicity, from the same causes which induced like 
changes in the pathogenic bacteria of the primary focus. ^" 
1. Billings, Focal Infection. 



458 The Practice of Osteopathy 

Osteopathic lesions play an important role, both in their relation- 
ship or bearing upon the tissues of a possible site for a focal infection 
and upon systemic conditions that derange general bodily tone. This 
has been definitely confirmed in those cases of rheumatism where cor- 
rection of the osteopathic lesions, with attention to hygienic measures, 
have resulted in recovery. This is a feature of osteopathic etiolog}^ and 
therapj^ that can hardly be over-emphasized, for an intact innervation, 
circulation and chemism of the organism is basic to both preventive and 
curative therapy. Rheumatism, like most diseases, is of local origin 
and if tissues and structures can be kept up to the normal, infectious or 
the other pathologic processes can rarely become active. . 

Pathologically, the sj^novial membrane is hyperemic. The mus- 
cles and ligaments are inflamed. The fluid is serous with more or less 
fibrin and leucocytes. In severe cases shght erosion of the cartilages is 
found. Acute rheumatism is rarely fatal; when death does occur it is 
generally due to the complications which arise. 

Symptoms. — The onset is usually sudden; although it may be pre- 
ceded by slight fever, aching in joints, chilliness, and sore throat. It 
generally involves the larger joints and is almost always multiple; it has 
a tendency to move from one joint to another. The pain in the joints 
usually develops rapidly with sHght chilKness and a rapid rise in the 
temperature from 102 to 104 degrees F. The pulse is frequent, often 
disproportionately to the fever. There are profuse acid sweats, often 
causing sudamina. There is loss of appetite and thirst is present. The 
urine is scanty, high colored, very acid, and deposits urates upon stand- 
ing. The tongue is coated and the bowels are constipated. The joints 
are reddened, swollen, extremely painful and tender to the touch. Every 
movement, jarring of the bed, or the pressure of the bed clothes is agonj'- 
to the patient. The blood is greatly deranged, anemia develops rapidly 
and there is well marked leucoc\i;osis. The duration varies from a few 
days to several weeks. 

Complications. — The temperatm-e may rise to 106 or 109 degrees 
F. ; this is often associated with delirium, great prostration and a feeble, 
frequent pulse. Endocarditis, pericarditis, myocarditis, pneumonia, 
pleurisy, iritis, chorea, convulsions and meningitis may occur. Coma 
may develop without preceding dehrium or convulsions; this is very ser- 
ious and may prove fatal. Subcutaneous fibrous nodules attached to 
tendons and fascia sometimes develop. They vary in size and are most 
cohimon in children and in young adults, occurring most frequently in 
the fingers, hands and wrists. They are also sometimes seen about the 



The Practice of Osteopathy 459 

elbows, knees, scapulae and spines of the vertebrae. They usually last 
a few days, somethnes for months, and generally develop during the 
decHne of the fever. Cutaneous affections, such as urticaria, erythema, 
nodosis, purpura and sweat vesicles sometimes appear. 

Diagnosis. — This is seldom very difficult; there are, however, 
several affections which resemble acute articular rheumatism. In sep- 
tic arthritis its association with some other septic process and the 
tendency of the inflammation to end in suppuration with more or less 
destruction of the joints, will determine the diagnosis. Septic arthritis 
may develop during the course of pyemia, puerperal fever, or acute 
osteomyelitis. Gout is rarely mistaken for acute rheumatism. Gout 
occurs later in life and usually affects the greater toe; history and mode 
of onset will usually render the diagnosis easy. In gonorrheal rheuma- 
tism the history of recent infection, its obstinate character and being 
generally connected with a single joint from the start are diagnostic. It 
especially affects the knee. Heart complications are rare. Rheuma- 
toid arthritis begins in the small joints; then attacks them all, leaving 
permanent deformity. There is no fever or sweats and the heart is not 
affected. Acute arthritis of infants usually attacks the hip or knee. The 
effusion becomes purulent. 

Prognosis^ — Recovery is the rule, but the prognosis nevertheless, 
must be guarded. Relapses and recurrences are common. 

Subacute Rheumatism. — In this form both the local and gen- 
eral symptoms are of a milder type and are more prolonged than in the 
acute form. The temperature seldom rises above 101 degrees F. The 
inflammation of the joints is not so severe and fewer joints are involved. 
It may last for weeks or months, and then it may pass into the chronic 
form. Usually though, when the course is prolonged, the joints return 
to their normal state. 

Treatment. — Place the patient in a room that is well ventilated and 
maintain a temperature of about 70 degrees F. Avoid draughts of air. 
The bed should be soft and smooth and blankets should be used. The 
diet should consist largely of milk, and let the patient drink freely of 
water. Oatmeal, barley water, egg albumen and meat juices may also 
be used. 

Treatment should be given along the entire spine, especially if the 
rheumatism changes fi-om one joint to another; otherwise treat the in- 
nervation directly to the affected joint. Correct any derangements 
that may be found along the spinal column and carefully relax the deep 
back muscles. Particular attention should be given to the bowels and 



460 The Peactice of Osteopathy 

kidneys. Also, treat the liver most thoroughly during each treatment. 
The liver is many times considerably enlarged and tender in rheumatism 
and a thorough treatment of it seems to favor a more rapid cure. 

Carefull}'^ treat the affected tissues. If 3'ou cannot treat over the 
joint, then manipulate the tissues above and below the joint; and usually 
after a few minutes' manipulation the swelling is somewhat reheved 
so that direct treatment of the joint can be given. It is best to wrap 
the inflamed joints in flannel if the pain is severe. Besides treatment of 
the innervation of the joint, hot appUcations will be helpful. Some 
claim that cold compresses are of aid to the inflamed joints. 

Complications are to be treated separately. Besides the ordinary 
fever treatment for the fever, the cold bath is very effectual. After 
convalescence has been estabhshed, the patient should be carefully 
protected for several days from cold and damp. For any stiffness that 
may persist, manipulation and hot baths will be quite sufficient. 

H. M. Still^ writes ''If the fever is not over 103 degrees I do not try 
to reduce it. . . After treatment in a majority of cases, the fever is re- 
duced within twenty-four hours unless complications have set in. These 
are usually of the heart, so no matter how mild the attack, keep this in 
mind. If the action is irregular and weak, stimulate it two or three 
times a day. If it is rapid and high fever, go to the vasomotor centers and 
reduce fever, then inhibit the heart action and keep the excretions active. 
If the joints are affected I always move them gently no matter how 
great the inflammation. As yet I have never had a case of rheumatism 
in which cardiac lesions or ankylosed joints were a sequela." 

If the tonsils are evidently badly diseased and osteopathic treatment 
does not clear them up do not hesitate to have them removed. 

Chronic Articular Rheumatism 

Osteopathic Etiology and Pathology. — This disorder should be 
studied in connection with arthritis deformans owing to similar sources 
of infection and various common factors. It usually develops slowly and 
follows an acute or subacute attack and is common among the poor, 
especially those exposed to damp and cold. Heredity, advanced j^ears, 
although the disease may appear at any age, and constant exposure to 
cold and wet are predisposing causes. Chronic lesions to the spinal 
column corresponding to the affected area are found. Too much stress 
from an osteopathic point of view cannot be placed upon the importance 
of lesions to both the digestive organs and to the joints especially in- 
1. Massachusetts Journal of Osteopathy, Jan. 1906. 



The Practice of Osteopathy 461 

volved. Then, in addition, particular attention should be given osteo- 
pathically or surgically, or both, to sites of focal infection. 

Pathologically, the capsules and hgaments of the joints are thick- 
ened also, the sheaths of the tendons around the joint, so that in long 
standing cases the movements are impaired. In severe cases the carti- 
lages ma}^ be eroded. Atrophy of the muscles covering the joints some- 
times occurs, especially when there is neuritis; thus producing marked 
deformity. This muscular atrophy is particularly marked when the 
shoulders or hips are involved. The atrophy is caused partly from dis- 
ease; in cases where the joint is distended with effusion, the wasting may 
be due to pressure upon the muscles or blood-vessels. 

Symptoms. — Several joints are usually affected; but it may be 
Mmited to one joint, particularly the knee, hip or shoulder. Pain and 
stiffness are the most common symptoms. The pain is increased upon 
motion, while the stiffness is often lessened by using the hmbs. The 
joints are slightly swollen, but seldom reddened and are usually tender 
upon pressure. All the symptoms are aggravated on the approach of 
stormy weather. There is fever but the general health is not greatly 
impaired. There may be distortion of the joints and ankylosis may oc- 
cur. Arterial degeneration and chronic endocarditis may develop as 
compKcations. 

Prognosis. — This should be guarded so far as a complete cure is 
concerned; although most cases are greatly benefited. 

Treatment. — The treatment of chronic articular rheumatism is 
largely correcting lesions of the spinal column, which affect the diseased 
tissues as well as the digestive organs, local treatment of the joints, and 
removal of focal infections. A certain percentage will respond to osteo- 
pathic measures alone, though surgery has a definite place in others. 
The joints and hmbs should be thoroughly treated so as to restore a 
better circulation and reheve the inflamed tissues. Wrapping the af- 
fected joint with cold cloths and then covering the cloths with flannel 
and oiled silk is often helpful. Due attention should be given the gen- 
eral health, such as nourishing food, free elimination and outdoor ex- 
ercise. 

Probably in some cases where the primary infection has been ehm- 
inated secondary foci are present and a general treatment will arouse 
sufficient reaction to cope with the condition. 



462 The Practice of Osteopathy 

Arthritis Deformans 

(Rheumatoid Arthritis) 

Definition. — A chronic affection of the joints, characterized by 
progressive changes in the cartilages and synovial membranes, and by 
new osseous formations restricting the motion of the joint and causing 
deformit.y. 

Osteopatliic Etiology and Patliology. — It is due to lesions of the 
spinal column affecting the spinal and sympathetic nerves as well as dis- 
turbing the circulation to the cord. Lesions of the spinal column and 
ribs are found corresponding to the innervation of the diseased joints. 
The osteopath has been able in every case to demonstrate chnically im- 
portant osteopathic lesions. In addition the symmetry of joint involve- 
ment, muscular atrophy, sweating, etc., point to nervous lesions. Falli 
found upon autopsy that the anterior horns had undergone atrophic 
changes. Nervous lesions are probably of a predisposing character 
while some infection is the exciting cause. A thorough search of the 
entire body should be made for foci of infection. Malnutrition, trauma- 
tism, exposure to cold, and pelvic diseases are important causative factors. 
In all cases lesions will be found disturbing the organs of digestion. Fe- 
males are more frequently affected than males. The disease is fre- 
quently seen in women suffering from ovarian and uterine troubles, 
especially at the menopause. Hereditary influence may be a factor, 
also auto-intoxication. The disease is most common between the ages 
of twenty and thii-ty. Mental worry, anxiety, grief and injury are also 
predisposing factors. 

Patliologically, in one class of cases, the cells of the cartilages and 
of the synovial membrane proliferate. The cartilages undergo atrophy, 
or may become soft, degenerate, and are absorbed, leaving the ends of 
the bone bare. The bones naturally atrophy and become smooth. In 
another class the edges of the cartilages where the pressure is slight, 
thicken and form outgrowths which ossify and enlarge the heads of the 
bones, forming osteophytes which greatly impair the motion; true anky- 
losis is rare. The synovial membrane becomes thickened, also the cap- 
sule and ligaments, thus greatly restricting the movements of the joints. 
The muscles around the joints atrophy. In the spinal cord atrophic and 
degenerative lesions are found. In Still's disease there is an enlarged 
spleen and marked changes in the joint. 

Symptoms. — Pain and swelling of the joints and fever and enlarge- 
ment of the lymphatics near the joint are characteristic. The spleen 



The Practice of Osteopathy 463 

is congested and later on there is gastro-intestinal disturbance. Multiple 
arthritis deformans, also known as Heberden's nodosites, is char- 
acterized by nodules developing at the sides of the distal phalanges. 
It occurs most frequently in women between the ages of thirty and forty, 
and gradually increases with age. At first the joints are swollen, tender 
and painful and then apparently become better. These attacks may ap- 
pear at different intervals while the nodules at the sides of the joints 
gradually increase in size. The larger joints are rarely affected. The 
progressive form may be either acute or chronic. The acute form at the 
onset may resemble articular rheumatism. It is more common in women 
between the ages of twenty and thirty, but may occur in children. Preg- 
nancy, recent delivery, lactation, the menopause, and rapid child bear- 
ing are common antecedents. There is swelling and tenderness of the 
joints and shght fever. Several joints are usually involved. The chron- 
ic form is most common. Symmetrical joints are usually involved. 
The affected joints slowly enlarge and are painful and red. Usually 
the hand is first affected; then the wrists, knees, toes, jaws and spine; in 
extreme cases every joint is affected. The vertebrae, spondylitis de- 
formans, may be attacked. The cervical spine may be alone involved, 
in which case the head cannot be moved up or down, although rotation 
usually remains. In some instances the entire spinal column is affected 
and may become perfectly rigid. In some cases there is hardly if any 
pain, while in others the pain is agonizing and is ahnost constant. The 
joints gradually become deformed, stiff and creak when moved; later they 
become completel.y ankylosed. This deformity is due partly to the 
thickening of the capsule, to the presence of osteophytes, and to the 
contraction of the muscles. These contractures flex the leg upon the 
thigh and the thigh upon the abdomen. Muscular atrophy increases 
the deformity. Numbness, tingling, pigmentation and glossiness of the 
skin, and local sweating may be present and are of trophic origin. 

The monoarthritic form affects old persons chiefly, and women 
more frequently than men. It affects particularly the hips, the knees, 
the shoulders, and the vertebral articulations. This is often caused 
by an injury. The muscles waste away and the knee-jerk is usually 
increased upon the affected side. 

Diagnosis. — Care has to be taken in not confusing it with rheu- 
matic fcvci- oi' gout. Radiographs should be made. 

Prognosis. — If treated early there is a fair chance for curing the 
disease. Advanced cases usually improve under treatment. The os- 
teopathic treatment should be persistent for at least sevoi-al months. 

Treatment. — Osteopathic treatment, if long continued in rliounia- 



464 The PRAfxicE of Osteopathy 

toid arthritis, has given satisfactory results, although owing to the ex- 
tent of the deformity, a cure in advanced cases cannot be expected. 
An important cause of the disease is probably a trophic or vasomotor 
disturbance to the tissues of the joint. Osteopathically, there is never 
any difficulty to locate disorders in the spinal column corresponding to 
the innervation of the involved joints. The fact that many of the joints 
are affected symmetrically indicates that the lesion is a spinal one in- 
volving the nerve center. During the incipiency marked improvement is 
the rule. 

A thorough attempt should be made in every case to discover the 
source of infection and remove it, though this does not preclude the 
essential osteopathic adjustment. 

The treatment consists of attempts to correct the spinal derange- 
ment and careful manipulation of the diseased joints to restore vitality 
and motion in them. The preceding simple, but effective treatment, 
must be continued two or three times per week for months or even years 
in order to be of particular value. Coupled with the specific treatment 
should be a careful consideration of the general health. The emunctories 
should be kept active and the food of the patient be nutritious. The 
osteopath should require the patient to take considerable physical ex- 
ercise at regular intervals, warm baths and plenty of fresh air. Mas- 
sage and friction of the diseased joints will be of aid in absorbing ef- 
fusions and in restoring the tone of atrophied muscles. Hot compresses 
are a help. The baths at various hot springs are sometimes of benefit, 
and change of climate is invigorating. 

O. J. Snyder^ has this to say: "I must be very emphatic, however, 
to here advise exceptional caution in your manipulative procedure. 
* * * You cannot attempt to move the joint, for, if you do you will 
cause excruciating pain and do irreparable harm in that you will cause 
breaking down of the cartilage and cancellous bOne tissue. Your first 
endeavor should be to reduce inflammation and to mitigate pain. * * * 
Osteopathically much comfort and reduction of pain can be accomplished 
by inhibition in the proper spinal areas. A little friction and very gentle 
extention or traction of the joint can be attempted as soon as the condi- 
tion of the joint, by the foregoing treatment, has been made possible. 
At no time should rotation or side-bending, or any other manipulation 
that produces irritation of tissue be attempted." 

In stout adult women a villous arthritis of the knees may develop 
owing to faulty posture and poor elimination. These conditions are 
often amenable to treatment. 

1. Journal of the American Osteopathic Association, November 1919. 



The Practice or Osteopathy 465 



Muscular Rheumatism 



I 



Debnition. — A painful disease of the voluntary muscles and of 
their fascia and the periosteum. It is regarded by many as a neuralgia of 
these muscles. The pain is greatly increased by motion and pressure. 

Osteopafliic Etiology and Pathology. — Osteopathic experience 
with cases of muscular rheumatism shows that the nerves, as they pass 
to and from the spinal muscles, are affected. The lesion is caused, prin- 
cipally, by subdislocations of the vertebrae, ribs or pelvis, according to 
the region involved. A gouty or rheumatic diathesis, heredity, exposure 
to cold and wet and previous attacks are predisposing causes. Men 
are more often affected, owing to their more frequent exposure. The 
disease affects persons of all ages. It occurs in acute, sub-acute and 
chronic forms. 

In cases of frequent recurrence focal infections and intestinal toxins 
are often important factors. Vertebral and muscular lesions, septic foci, 
intestinal stasis, exposure to cold and drafts are principal causes. 

Pathologically, there is swelling of the muscles of the nature of 
myositis. In chronic cases there is often atrophy of the muscles, due 
to interference of the trophic nerves. 

Symptoms. — These are generally local and are never accompanied 
by marked constitutional disturbances. There is seldom fever, and the 
pulse is only sHghtly increased in frequency. Pain is the chief symptom ; 
it is increased by motion or pressure. Tenderness is generally present 
and there may be swelhng of the tissues. Rheumatic nodules have been 
found. The duration is usually three or four days, though it may last 
longer with frequent recurrences. 

Lumbago is a painful affection of the muscles of the lumbar area 
and their tendinous attachments. The onset is generally sudden. In 
severe cases it sometimes renders the patient helpless. In torticollis, 
or stiff neck, the muscles of the side and back of the neck are affected. 
It is usually confined to one side of the head. Any attempt to turn the 
head causes a sharp pain. In pleurodynia the intercostal muscles, and 
sometimes the pectorals and serratus magnus, are affected. It usually 
affects but one side, more frequently the left ; it is the most painful form 
of the disease, since the pain is aggravated by breathing. The respira- 
tory movements are consequently restricted on the affected side. The 
absence of fever and physical signs will distinguish it from pleurisy. In 
intercostal neuralgia the pain follows the distribution of the nerves 
and there are tender spots along their courses. Cephalodynia affects 



466 The Practice of Osteopathy 

the muscles of the scalp. Scapulodynia, omodynia and dorsodynia 

affect the muscles of the shoulder and upper dorsal. Abdominal rheu- 
matism affects the muscles of the abdomen. 

Prognosis. — The prognosis is good. Favorable results are the 
general rule under careful treatmejit. 

Treatment. — Muscular rheumatism is usually an easy affection to 
cure. The cause of the disturbance is generally found in the region in- 
volved, and is due, in the majority of cases, to some dislocated tissue, 
usually osseous, that irritates the nerves to the muscles. In addition to 
correcting the lesions, removal of septic foci, free elimination, lessened 
diet, stretching of the muscles, application of heat, ironing and rest are 
beneficial. 

In lumbago there is invariably found a slight lateral deviation of 
some vertebrae along the lower dorsal or lumbar region. Occasionally 
deformity of the vertebrae, asymmetry, or arthritis are factors. The 
radiograph may be a diagnostic aid. Occasionally, a floating rib or an 
innominate becomes displaced. Stretching the loins by placing the pa- 
tient upon his side or back and flexing the thighs on the abdomen is 
very beneficial. Maintain the tension for three or four minutes. Hot 
fomentations and rest are helpful. 

Torticollis, or stiff neck, is generally due to a lesion of the middle 
cervical vertebra;. The lesion is usually between the third, fourth and 
fifth vertebrae, occasionally as low as the second dorsal. A reduction of 
the subdislocation will often relieve the attack. Stretching of the muscle 
and application of heat will also be of aid. In some cases of torticollis 
(chronic) there is a curvature of the cervical spine, and occasionally the 
nmscles are more or less fibrinous. Surgical measures may be instituted. 
In such instances a cure cannot always be accomplished. The tonsils, 
nose and teeth should be examined for sources of infection. 

A few cases of acute torticollis are caused by some of the deep mus- 
cular fibres becoming caught around a process of a vertebra. Severe 
contraction of the muscles by cold or extensive rotary flexions of the 
neck, may result in torticollis. Occasionally a case is found due to in- 
jury at birth. The cervical vertebrae should be carefully examined. The 
spinal accessory is the nerve generally involved. Lesions to the spinal 
accessory occur commonly at the third, fourth and fifth cervicals, or 
the atlas and axis. The muscles involved in torticollis are the sterno- 
cleido-mastoid, trapezius, splenius and scaleni. Operations should not 
be performed until a thorough course of treatment has failed to relieve. 



The Practice of Osteopathy 467 

Pleurodynia is often a neuralgia of the pleural nerves. It is usually 
caused by subdislocations of the ribs exactly over the regions involved. 
Occasionally, a lesion may exist to the corresponding vertebra, but rarely. 
The rib is at times completely dislocated. AppHcations of heat and rest 
of the part are of aid. Strapping of the region will give considerable re- 
lief. 

In cephalodyina the muscles of the scalp are generally involved 
by lesions in the upper five cervical vertebrae. In scapulodynia, omo- 
dynia and dorsodynia the muscles of the shoulder are usually affected 
by displacements of the second and third ribs, although the lesion may 
be found sHghtly lower in the ribs, or in the corresponding vertebrae. 
The lower cervical vertebrae may also be at fault. In recurring and 
chronic cases carefully examine for infectious sources. Dislocations of 
the shoulder occur frequently; and muscular fibres may slip out of the 
bicipital groove (rarely) . In a few cases muscles may become contracted 
about the coracoid process, or the acromial end of the clavicle may be- 
come dislocated. 

Abdominal rheumatism is generally caused by lesions in the 
lower six dorsal vertebrae, which involve the innervation to the muscles. 
In some cases lesions of the lower ribs are found, and in a few instances 
a lesion may be discerned in the upper lumbar vertebrae. 

Myalgia of the upper extremity is caused by lesions of the cervi- 
cal or upper dorsal vertebrae or upper ribs. Occasionally some trouble 
may be found in the shoulder or elbow joints. In the lower extremity 
lesions may be found in the lower dorsal or lumbar vertebrae, or there 
may be derangements of the pelvic bones. Occasionally disorder is 
found at the hip and knee joints. 

Gout 

Definition. — A nutritional disorder in which there is an abnormal 
accumulation of uric acid and other purin bodies in the blood and tis- 
sues; and arthritis, deformity of joints and visceral derangements being 
the characteristic features. 

Osteopathic Etiology and Pathology. — Hereditary influences 
are the predisposing factors of about one-half of the cases of gout. Men 
are more frequently affected than women. It rarely develops before 
the age of thirty. Overeating, sedentary habits, drinking alcohol, es- 
pecially fermented drinks, and lead poisoning are predisposing factors. 
Emotional disturbances may excite an attack. Gout is not confined to 
the rich by any means; but there is also a "poor-man's gout," due to 



468 The Practice of Osteopathy 

poor food, unhygienic surroundings, and to an excessive use of malt 
liquors. Uric acid seems to be a causative factor, but whether there is 
an increased formation or a diminished excretion of the uric acid has not 
yet been fully decided. The ultimate result is the same in either case; 
there is an accumulation of uric acid and other purin bodies in the blood, 
which is responsil)le for some of the effects of the disease. 

Osteopathic experience with cases of gout shows that lesions affecting 
the nervous system are important factors that control uric acid accumula- 
tion or excretion. The nerve centers controlhng the affected portions of 
the body are ahiiost invariably involved, as well as the nerve control to 
the digestive and excretory organs. A neurosis of these nerve centers 
probably occurs and is thus a predisposing cause of gout. Considerable 
can be accomplished in the treatment of gout by careful examination of 
the spinal column, in the region corresponding to the innervation of the 
affected area, for vertebral lesions, and correcting them. Usually, sUght 
dislocations of the bones of the foot are found, when that region of the 
body is involved. The most common subdislocations of the foot are in- 
volvements of the astragalus with its articulations and the metatarsals. 

Pathological changes are those of the joints principally. There 
is deposit of uric acid in cartilages, synovial membranes and ligaments. 
The joint of the great toe is most frequently affected, then the fingers, 
ankles, knees, hands and wrists. The exudates become hard and are then 
called tophi. In severe cases the cartilages of the ears, nose, eyelids and 
larynx are involved. Finally the joints become stiff, deformed and 
ankylosed, and sometimes there is ulceration. 

The kidneys are usually the seat of chronic interstitial inflammation 
with a deposit of urates. The heart and blood-vessels almost alwaj^s 
present changes. Arterial sclerosis is quite a constant lesion; the left 
ventricle of the heart is hypertrophied. Urate of sodium has been found 
deposited upon the valves. There is an excess of uric acid in the blood. 
Chronic bronchitis, emphj^sema and asthma are among the changes in 
the respiratory system. 

Symptoms. — In acute gout, before the attack, the patient maj^ 
complain of dyspeptic disorder, restlessness and twinges of pain in the 
small joints. He is apt to have irritabihty of temper and depression of 
spirits. The first symptom of the attack is great pain in the metatarso- 
phalangeal joint of the great toe, which usuall}' comes on suddenly at 
night with swelling, heat and discoloration of the joint. The tempera- 
ture rises to 102 and 103 degrees F. Towards morning the symptoms 
generally abate to recur again the next night. This lasts for several 



The Practice of Osteopathy 469 

days, the symptoms graduallj^ abating. The urine is scanty, high col- 
ored, of high specific gravity and acid in reaction. It deposits urates and 
often contains a small quantity of albumin. There may be gastro-intes- 
tinal S3anptoms — pain, vomiting, diarrhea, faintness and a rapid, feeble 
pulse. Pharyngitis is an occasional symptom. The cardiac symptoms 
are pain, shortness of breath and irregular action of the heart. These 
attacks may appear with varying severity. In some cases there may be 
severe cerebral symptoms. 

Chronic gout follows repeated attacks of the acute form. The ar- 
ticular symptoms continue for a longer time and the condition extends to 
other joints. The chalk deposits slowly increase until the joint becomes 
swollen and deformed. The morbid changes already described are char- 
acteristic. The urine is increased in quantity, is of low specific gravity 
and may contain albumin and hyaHn and granular casts. Involve- 
ment of the heart and blood-vessels gradually occurs. 

Irregular gout or lithemia is seen in persons who have been gouty 
or have a hereditary predisposition. It includes a set of symptoms that 
are not alone distinctive, but when taken with this gouty tendency, all 
forms of irregular gout can be recognized. There are various gastro- 
intestinal disturbances; cutaneous eruptions; heart and blood-vessel 
changes; pains in the various muscles and joints; nervous symptoms, 
as headache, neuralgia and neuritis; urinary symptoms, and pulmonary 
and ocular disorders. 

Diagnosis. — Only the irregular form of gout should be difficult to 
diagnose. Differentiation is to be made from arthritis deformans and 
acute and chronic rheumatism. 

Treatment. — The hygienic treatment of gout is very essential. 
The patient should live a quiet life, avoiding mental and physical strains. 
Plenty of fresh air, exercise and regular hours should be insisted upon. 
AlcohoHc drinking should be avoided and the food taken in moderate 
quantities. Keeping the skin active by the use of cold baths, if the pa- 
tient is strong, and warm baths should he be weak, is a helpful measure. 
The dress of the patient should be warm and suitable for the chmate. 

A regulated diet of nutritious food, taken at regular hours, is neces- 
sary. Each patient should receive separate instructions as to diet. 
The food given may be small amounts of beef, mutton and chicken, 
with fresh vegetables; with the exception of strawberries, tomatoes and 
bananas, fruits may be used; fats, milk and stale bread are also suitable. 
The patient should avoid tea, coffee, pastry, hot breads, highly seasoned 
dishes, and such articles. The free use of water is beneficial. 



470 The Practice of Osteopathy 

The osteopathic treatment consists of careful correction of the 
lesions of the spinal column in order to free the nerve force to the affected 
region. The spinal treatment in gout is the most essential treatment 
and is effective. A most thorough examination should be made of the 
tissues about the diseased area; in the foot the astragalus oftentimes is 
.^ubdislocated from its articulations, causing obstructions to the local 
vessels and nerves. The metatarsal bones should receive due attention, 
as occasionally one of the bones corresponding to the affected tissues is 
dislocated, usually downward. All the joints between the diseased tis- 
sues and the spinal nerve centers should be carefully manipulated so as 
to favor a better circulation. During a severe attack of gout, besides 
careful treatment of the blood supply to the diseased region, wrapping 
the joint in cotton wool and appl3'ing warmth and moisture to the joint 
may be helpful. 

The kidneys, liver and bowels are to be kept active. A Ught treat- 
ment to the kidneys and liver each time is verj^ helpful in aiding the or- 
gans to eliminate the waste material, and especially in controlling any 
inflammation that may exist in the kidne.y. The essential treatment in 
gout is to reUeve the disorder of the nerve centers, to increase the ac- 
(ivdties of the emunctories and to regulate the hygiene of the patient. 

Diabetes Mellitus 

Definition. — A nutritional disorder in which there is an abnormal 
amount of sugar in the blood, characterized b}^ an excessive urinary dis- 
charge, in which grape sugar is constantly present, and by a progressive 
loss of flesh and strength. 

Osteopatliic Etiology and Patliology. — Almost invariably there 
will be found a posterior dorso-lumbar curvature wherein the spinal col- 
umn tissues are much contractured. This condition probably involves 
the sympathetics (vasomotor and trophic) to the pancreas, liver and in- 
testines. Important lesions may also be found as high as the occiput. 
Tenderness and congestion over the abdomen, especially the liver, are 
frequent. It affects men more frequently than women and is a disease 
of adult hfe, ranging between the ages of thirty and sixty, though cases 
have occurred in the very young. It is more serious in the young, the 
very young seldom recovering. Hereditary influences are believed 
to be a predisposing cause. It affects the better classes principally and 
especially those of a neurotic temperament. The Hebrew race is 
specially predisposed. The colored race is seldom affected. 



The Practice of Osteopathy 471 

Obesity, certain chronic diseases (malaria, gout, syphilis), occupa- 
tions taxing the mind, and pregnancy are predisposing influences. In- 
jury or disease of the spinal cord or brain frequently cause diabetes, 
especially anj^ irritation of Bernard's diabetic center in the medulla. 
Derangements of the endocrine system are important. Injuries to the 
spine, chiefly in the dorso-lumbar and sacral regions, and to the abdomen, 
and diseases of the pancreas or liver are, as has been stated, oftentimes 
causes. Lesions to the spine maj^ disturb the glycogenic function of the 
Hver, the glycolytic ferment of the pancreas, or produce an ahmentary 
glycosuria. Extirpation of the pancreas is immediately followed by dia- 
betes, but if a fragment of the pancreas is left it is not always followed 
by diabetes. The normal amount of sugar in the blood is 1-1000 while 
in diabetes the amount of sugar is 3 to 4-1000 up to 7 or 8-1000. The 
healthy kidney will not excrete sugar when it is at the normal ratio. 
Concerning the presence of acetone-bodies von Noorden^ says: "The 
excretion of acetone-bodies may serve, like glycosuria, as a measure of the 

intensity of the diabetic disease it will be at once understood 

that in no other disease do the acetone-bodies occupy so important a 
position as in diabetes." Irritation of the centers of the vasomotor 
nerves to the liver or direct stimulus to the liver cells is followed by 
glycosuria. Interference with the pneumogastric nerve also influences 
diabetes. 

Pathologically, the liver is enlarged, firmer and darker in color 
than normal. Often there is fatty degeneration of the organ. The 
pancreas is diseased in about one-half of the cases of diabetes, especially 
the islands of Langerhans. The lesions found are granular atrophy, 
occlusion of the pancreatic duct, atrophy from pressure, fat necrosis, and 
sometimes it is small, soft and anemic. The kidney changes are those of 
catarrhal nephritis. In the fatty degeneration hyalin changes take place. 
The heart is hypertrophied in a few cases. Arterial sclerosis is frequently 
met with. In the lungs bronchitis, pneumonia and tuberculosis occasion- 
ally develop. In the stomach and intestines catarrh is common. The 
blood presents an increase of sugar. In the nervous system are found 
many lesions, especially congestion, extravasation and sclerosis of the 
brain; disturbances of the posterior part of the cord, and congestion and 
sclerosis of the sympathetic gangha. The bony lesions, however, (al- 
most invaria})ly a posterior lower dorsal and lumbar) must involve the 
sympathetics, via the splanchnics, to the extent of profound metaljolic 
disturbance, for in no other way can llie results of osteopathy l)e explained. 

1. Diabetes, p. 90. 



472 The Practice of Osteopathy 

The importance of specific treatment at this point cannot be over 
estimated. 

Symptoms. — The onset is gradual; thirst and frequent micturi- 
tion being the first symptoms noticed. After an injiu-y or a sudden, 
severe nervous shock, diabetes may set in abruptly'. As the disease pro- 
gresses there will be marked thirst, polyuria, an abnormal appetite, wast- 
ing and debility. The tongue is dry, red and coated. There is con- 
stipation and the skin is dry and harsh. Temperature is often subnor- 
mal; pulse frequent with increased tension. 

In some cases the urine is not increased in quantity; usuallj^ how- 
ever, the amount varies from four to five pints to several quarts in twent}^- 
four hom*s. It is pale in color, of high specific gravity and acid reaction. 
Sugar is present in variable quantities from one or two per cent to five 
or ten per cent. Sugar in the urine must be constant in order that the 
affection is a true diabetic one. Albumin is often present; urea is in- 
creased and uric acid may be slightly lincreased. Acetone-bodies are 
often found and usually indicate a more serious condition. 

Diabetic Coma is the most important and gravest complication. 
There is either a sudden or gradual loss of consciousness. This may oc- 
cur after some form of exhausting exercise. There maj^ be previous head- 
ache or a feehng of intoxication. It may be preceded by nausea, vomit- 
ing, colicky pains or some local affections, such as pharyngitis or pulmon- 
ary compMcations. Peripheral nem-itis, neuralgia, numbness, are pos- 
sible symptoms. Impairment of hearing, cataracts, strabismus, diabe- 
tic retinitis and atrophy of the optic nerve may occur. The sexual 
function is lost early in the disease. Eczema, with burning and itching 
of the labia and vicinity, (and in men a balanitis), furuncles, boils and 
carbuncles are common. Gangrene and edema are not uncommon. 
Acute pneumonia, bronchitis and tuberculosis are possible complications. 
Progressive loss of flesli is a serious indication. 

Diagnosis. — The diagnosis is easy, as there is no other disease 
with which it can be confounded. Careful urinatysis should always 
be made. Examination for acetone, diacetic acid and oxybutyric acid 
is valuable. 

Prognosis. — Many cases have been cured by osteopathic measures 
while nearly all treated have been benefited. If the patient is put upon a 
diet free from carbohydrates, in mild cases the sugar wall disappear, while 
in severe cases it will still be present. Mild cases usually yield readily to 
treatment. In cases over forty years of age the outlook is quite favorable, 



The Practice of Osteopathy 473 

but in cases under forty, and especially the young, the prognosis is not so 
favorable. In cases under puberty the results are apt to be fatal. Stout 
persons bear diabetes better than lean. All cases are liable to complica- 
tions, which render the prognosis more serious. It is a disease of long 
duration, although death has occurred in a few weeks. 

Treatment. — In nearly all cases of diabetes mellitus examined 
there have been found posterior conditions of the lower dorsal and lumbar 
regions. The posterior curve has always been fairly well marked and 
generally is a symmetrical curve. By that is meant a spinal curve that 
is not irregular and the relation of the various vertebrae, one to the other, 
is not seriously deranged. Correction of this condition of the spinal col- 
umn has almost invariably given satisfactory results and in the majority 
of cases the condition of the patient has improved remarkably, and many 
entirely cured. To get the best results the patient should be laid on 
his side on the operating table and the knees drawn up so that the thighs 
are flexed upon the abdomen. The osteopath standing in front of the 
patient throws his weight against the flexed thighs and reaching over 
upon the spinal column springs the entire weakened portion of the spine 
toward its normal position, stretching the spinal column to separate each 
vertebra from its neighbor so that the deranged nerves, as they pass 
through the intervertebral foramina, may be released. Meeker^ re- 
ports a case with a marked kyphosis which was treated two years before 
enough motion could be had between the vertebrae to produce any results, 
but after that they were favorable. Direct treatment to the abdominal 
organs to correct Hver congestion and stimulate the pancreas and increase 
activity of the intestines is essential. 

The nerves affected by the posterior pathological curve of the spine, 
mentioned above, and by separate lesions that may exist within the 
pathological curvature, are probably the vaso-motor nerves to the portal 
system, pancreas and the intestines. The vaso-motor nerves to the por- 
tal system branches are given off principally from the fifth to the ninth 
dorsal vertebrae, although fibres may escape from the cord as low as the 
first lumbar vertebra. The nerves to the intestines are given off princi- 
pally from about the ninth dorsal to the lower lumbar vertebrae. Pos- 
sil)]y there are nerve fibres direct to the hepatic cell protoplasm. 

How lesions in the dorso-lumbar region cause diabetes mellitus is an 

important question and is hard to answer. An unnatural acceleration 

of the portal circulation may cause an increased quantity of sugar to 

pass to the liver, resulting in part of the sugar not being changed into 

1. Journal of the American Osteopathic Association, Oct., 1904. 



474 The Practice of Osteopathy 

glycogen and thus passing into the circulation ; or a paralysis of the vaso- 
motor nerves to the liver causes congestion and slowness of the blood 
stream. Thus a disturbed circulation of the liver may cause accumulation 
of sugar in the liver, so that the blood ferment has time to act upon the 
glycogen and transform it into sugar; or there may be a saccharinit}^ of 
chjde or blood in the portal vein, due to an impeded conversion of sugar 
in the intestines into lactic acid; or there may be an accelerated absorp- 
tion of sugar due to an abnormal state of the intestines; or the nervous 
control to the pancreatic functions may be disturbed. Hence, one or 
many pathological changes may occur and influence a case of diabetes, 
due to a disordered dorso-lumbar region. 

The center for the hepatic vasomotor nerves, "diabetic center," 
is in the floor of the fourth ventricle at the level of the origin of the vagi 
nerves. A lesion of the "diabetic center" or an obstruction to the pneu- 
mogastric anywhere along its course may cause diabetic symptoms; 
hence, there may be lesions of the cervical region that would affect reflex- 
h' the diabetic center, or lesions of the pneumogastric may occur, partic- 
ularly at the atlao or axis, and cause diabetic symptoms, or, at least, these 
may influence the course of a case of diabetes melhtus. Or the upper 
cervical lesions may disturb the pituitary gland which is of importance 
in carbohydrate metabolism. 

There are nerves from the superior and inferior cervical ganglia of 
the sympathetic that have considerable influence upon the hver. These 
nerves do not pass down the cord to the splanchnics, but pass in the sym- 
pathetic to the ceUac and hepatic plexuses and then to the liver. Stim- 
ulation of these nerves causes the hepatic vessels at the periphery of the 
liver lobules to become contracted. Possibly in a very few cases, a stag- 
nation of blood in other vascular regions of the body may cause the 
blood ferment to accumulate in the blood to such an extent that diabetic 
symptoms occur. 

Dietetic treatment is essential, but is not so necessary as some 
medical authors would have us believe. A regulated diet should be 
insisted upon in all cases, but one should not go to extremes in dieting, 
A complete ehmination of the carbohydrates is no longer considered the 
])est treatment, as it withdraws too important an element from the diet, 
producing weakness without any corresponding return for good. A 
patient's appetite is often inordinate and it will be necessary to regulate 
the quantity and character of foods. Proctor^ mentions a case which re- 
covered when carbohydrates were restored, as the patient was too starved 
1. Journal of the American Osteepathic Association, Oct., 1904. 



The Practice of Osteopathy - 475 

to build up. Under osteopathic treatment much more liberty can be 
allowed in selection of foods. Von Noorden^ reported a number of cases 
in which excretions of sugar continued upon the strict anti-diabetic diet, 
but which were sugar free when they received a large amount of oatmeal 
along with some vegetable proteid or white of egg and butter, other car- 
bohydrates being excluded. It is suggested by the editor of the Series 
that the oatmeal may be used alternately with diabetic diet, and reheve 
the monotony greatly. It can also be used as a test of the patient's 
digestive and sugar destroying powers. The following food may be in- 
cluded in the dietary: 

Animal Foods. — Meats of every variety, except Hvers; game, poultry, 
fish and eggs. 

Vegetables. — Cabbage, cauliflower, celery, lettuce, green string 
beans, the green ends of asparagus, tomatoes, spinach, mushrooms, cu- 
cumbers, watercress, young onions, or any other green vegetable. 

Bread and Cakes. — Made of gluten flour, bran flour or almond 
flour; griddle cakes, biscuits, porridges, etc., may be made of these flours. 

Beverages. — Skimmed milk, buttermilk, coffee and tea without 
sugar, and carbonated water. 

Relishes. — Pickles, cream cheese and nuts of all kinds except chestnuts. 

Fruits. — Oranges, lemons, cranberries, cherries, strawberries, all in 
moderate quantities. 

Other foods may be used, but each case requires a thorough studj^ 
in order to determine what is best to do. 

Various foods should be tested out and controlled by urinalysis. 
The point is to increase metabolism so that the body can store up con- 
siderable carbohydrates without the appearance of sugar in the urine. 

In severe cases Allen's fasting treatment to be followed by a low 
diet should be instituted. However, it should be remembered that the 
correction of dorsal and upper cervical lesions is invaluable. 

Mental excitement and worry should be avoided as much as possible. 
Frequent bathing and regulated exercise will be of considerable value. 
The diabetic patient should have a well ventilated room and plenty of 
rest and sleep; flannels are to be worn next to the skin the year around. 

Various symptoms and complications are liable to arise, which 
the competent osteopath is prepared to meet l)y following general rules. 

Keep the bowels open. And frequently examine for acetone and 
diacetic acid. If there are any symptoms of coma fast the patient, and 
neutralize the acid intoxication with bicarlwnate of soda until the urine 
is alkahne. 

1. Practical Medical Scries, HK)."). 



476 The Practice of Osteopathy 

Diabetes Insipidus 

(Polyuria). 

Definition. — A constitutional disorder in which there is a contin- 
ued excessive secretion of urine, free from albumin and sugar. There 
is constant thirst. 

Osteopatliic Etiology and Patliology. — This disease is more 
frequent in males than in females. It occurs most commonly between 
the ages of twenty and thirty. It is due to chronic disturbances of the 
nerves. The lesions usually found upon osteopathic examination are 
lateral derangements of the vertebrae in the renal splanchnic region, 
(ninth to twelfth dorsal inclusive) or a slight kyphosis in the same locality. 
Such lesions probably affect the central nervous system in the region of 
the sympathetic nerves to the kidneys, by a paralysis of the muscular 
coat of the renal vessels. The disease may be associated with other con- 
ditions, as injuries and diseases of the nervous system elsewhere; ex- 
posure to cold; prolonged debility and fatigue; cerebral diseases, as men- 
ingitis, paralysis of the sixth nerve, tumor of the brain, and blows on 
the head; injuries of the cervical region; sunstroke; cerebrospinal fever; 
malaria; syphilis; pregnancy; hysteria; hereditary influences, and drink- 
ing too freely of cold water. There are many diseases and conditions 
which may be associated with diabetes insipidus; and which act as irri- 
tants, directly or reflexly, upon the center in the medulla oblongata 
(which is just above the diabetic center), or upon the sympathetic ganglia 
in the abdominal region. Thus, there is a vasomotor neurosis, due either 
to central or reflex lesions. 

Second in importance to lesions of the renal splanchnics are le- 
sions of the upper cervical region. Irritations in the cervical region 
may act upon the center in the medulla or the lesions may affect some 
of the sympathetic fibres as they pass from the brain to the renal sym- 
pathetics. The pituitary gland may be disturbed. Probably axis 
and atlas lesions are factors. 

Lesions of the nerve centers and of the sjmipathetic ganglia have 
been found upon post-mortem examination, but they are not constant. 
Nervous lesions have been found in the region of the base of the brain. 
The kidneys are sometimes congested and enlarged. The tubules may 
be dilated. 

Symptoms. — Great thirst and an enormous secretion of urine of 
a pale, watery and slightly acid nature are the characteristic symptoms. 
The skin is usually dry and harsh, the bowels are constipated, and the 



The Practice of Osteopath i 477 

appetite may be voracious. The health on the whole is quite perfect, 
although if the affection is not arrested, considerable loss of flesh and 
strength may result. There is a tendency for the disease to become 
chronic. 

The nervous lesion causing polyuria may be the outcome of a debil- 
itated condition of long standing or the symptoms may occur suddenly. 
Preceding the large flow of urine such symptoms as nervousness, irrita- 
bility, headache, sleeplessness, failure of memory, and inability to con- 
centrate the mind commonly occur. Other symptoms may be present 
in addition, as debihty, diarrhea, epigastric and lumbar pains, and im- 
paired sexual function. 

Diagnosis. — The diagnosis is not difficult. Thirst, polyuria and 
the absence of albumin and sugar characterize the disease. In diabetes 
melUtus, finding of grape sugar in the urine would at once exclude poly- 
uria. In paroxysmal diuresis, the increased amount of urine is not 
permanent. In interstitial nepliritis, there is albumin, casts, etc. 

Prognosis. — Depends upon the cause. The disease yields to 
treatment much quicker than diabetes mellitus and is without doubt 
much less serious. The disease, in a large majority of cases, can be 
cured. Under osteopathic treatment most cases will yield good re- 
sults or be cured in from a few weeks to six months. 

Treatment. — The treatment of the disease causing diabetes in- 
sipidus is of first consequence, but frequently such a disease is undiscover- 
able. There is often a tendency toward nem^asthenia; consequently, 
habits, environment, etc., should be carefully attended to. Examine 
for sexual, rectal and other reflex irritations. 

Correcting lesions of the renal splanchnics is important; in fact, in 
a fair number of cases treatment of this locaHty will entirely cure the dis- 
ease. A very effective treatment, in addition to the ordinary methods 
of treatment, is to have the patient lie flat upon the back while the osteo- 
path reaches around the patient on either side, placing the fingers firmly 
upon the transverse processes of the lower dorsal vertebrae and spring- 
ing the spine forward by lifting upward on the patient, enough even to 
raise the patient from the surface he is lying on. This treatment is 
especially effective in lessening the increased amount of urine. At- 
tention should be given to the false ribs on either side and to the condi- 
tion of the spine below and above the renal splanchnics. The cervical 
vertebrae should be examined carefully for disorders, and if any are found 
they should be removed at once, if possible. 



478 The Practice of Osteopathy 

Hygienic treatment is of as much importance as in diabetes mellitus. 
The clothing should be warm, warm baths taken, and general friction and 
care of the skin utiHzed so that the circulation may be somewhat di- 
verted from the kidneys. Restriction of water is not always necessary, 
except in cases where excessive drinking has become a habit, as the thirst 
is caused by the diuresis and not the diuresis by the large ingestion of 
water. Regulate the diet and see that the bowels are acting normally. 

Rickets 

Rachitis 

De&nition. — A constitutional disease of children, characterized 
by impaired nutrition and changes in the growing bones, causing deformi- 
ties. The physical growth is disturbed and the bone deformity is due to 
an over growth of cartilages and delayed calcification. 

Etiology and Patliology. — Rickets may occur in the new-born, 
but it rarely begins before the child is six months old. It is a disease of 
the first and second years of Hfe. Heredity is probably not a factor but 
certain races, especially the Negro and Italian, have a tendency to be 
rickety. The disease is much more common in the large cities than 
in rural districts; also it is more common in Europe than America. The 
disease is most frequently met with among the ill-fed and badly housed 
poor of the large cities, though it is not rare to find it among the well-to- 
do. Lesions to the digestive organs predispose. Breast-fed children 
seldom have the disorder. Improper or insufficient food (a diet too low 
in fats and proteins) bad air, want of sunhght, prolonged lactation, expos- 
ure to cold and dampness are presisposing factors. 

Pathologically, the most marked changes are seen in the long 
bones and the ribs. The cartilage between the epiphysis and shaft is 
thickened and is soft and irregular in outline. Underneath the per- 
iosteum the tissue is spongy. Microscopic examination shows an increase 
of proKferation of the cartilage cells with scanty calcification. The 
bones are soft and there is a diminution in the calcareous salts. In a 
word ossification is delayed and the bones are not perfectly developed. 
In the cranium the frontal and parietal eminences are prominent, while 
the top of the head and the occiput are flattened, giving the head a square 
appearance. The fontanelles remain open until the second or third 
year of Hfe. The ribs become affected very early. At the point where 
the ribs join the costal cartilages, bulging occurs, forming the so-called 
"rachitic rosary." The normal shape of the chest walls is markedly 
changed. Just outside the junction of the ribs with the cartilages, the 



r 



The Practice of Osteopathy 479 

ribs fall in, producing a shallow depression, while the sternum and car- 
tilages are pushed forward. The bones of the leg may be distorted. 
The normal curves of the spine are occasionally disturbed. The liver 
and spleen are often increased in size. 

Symptoms. — The onset is slow. In many cases digestive disturb- 
ances, with their usual effect upon the nutrition, precede the appearance 
of the characteristic lesions. The child is irritable and restless, and there 
is usually sHght fever and profuse sweats. The child is often languid, 
pale and feeble. The lymph gland are enlarged. The tissues are soft 
and flabby and skeletal changes begin to make their appearance. Among 
the first are changes in the ribs and head, already described under pathol- 
ogy. Changes sometimes occur in the bones of the face, particularly 
the maxillae. Dentition is delayed. The spinal column is frequently 
curved antero-posteriorly or laterally. The long bones are curved and 
their extremities become thickened. The pelvis is distorted and twisted 
and in women this may seriously compKcate labor. "Chicken breast" 
and "bow legs" are common, as well as muscular weakness, and the child 
walks late. The abdomen is large and prominent, due to flatulency and 
to the enlargement of the liver and spleen. 

Diagnosis and Prognosis. — By observing the symptoms, diagno- 
sis is not difficult. Prognosis should be guarded, owing to danger from 
other diseases; still, on the whole, prognosis is fairly favorable. 

Treatment. — Rickets being a disease of malnutrition due to weak- 
ness of the digestive organs, improper food, or to influences of disease, 
the treatment must be principally following hygienic rules and good 
dieting. The child under six months, if not nursed satisfactorily by the 
mother, should be given diluted cow's milk. Salts may be obtained from 
barley gruel and whole wheat. Diluting the milk, with barley water is 
highly recommended. Fresh meat juice and cream are invaluable. 
If curds are found in the stools, the digestion is not perfect and is usually 
due to overfeeding the child. The child should be out doors as much as 
possible. Fresh air is a necessity. The worst air outside is better than 
the best air of the house as far as purity is concerned. Protect the child 
carefully with warm clothes, and when sitting or walking the child should 
be supported. Baths will be found beneficial. 

In the older child, beef juice, light meats, yolks of eggs, green veg- 
etables and fruits may be given. Lessen the amount of carbohydrates. 
Careful osteopathic treatment of the various affected tissues of the child 
will aid a great deal in correcting deformities. Attention to the lesions 
found will also aid in increasing the nutrition to the involved tissues. 



480 The Practice of Osteopathy 

as well as correcting digestive disturbances. This, also, is of distinct 
benefit in improving the assimilation of hme salts. Possibly treatment 
of the "nutritional" centers, (fourth dorsal and fourth lumbar) would 
be effectual. Carefully guard against comphcations of the nervous and 
respiratory systems. After ossification the deformities may be corrected 
by the orthopedic surgeon, though in the young child considerable can 
be accomphshed b}-- repeated attempts at straightening by bending and 
molding the long bones. All those conditions which predispose to rickets 
should receive attention; chief among these is the care of the nutrition 
of the mother during pregnancy. Nursing should be regulated, and 
possibh^ future pregnancies discouraged. 

Obesity 

Definition. — Obesity is essentially a nutritional disease and is an 
inconvenient accumulation of adipose tissue in the body, sometimes im- 
pairing the bodily function. With some individuals obesity is a normal 
condition. In others it means impaired health, especialty poor ehmina- 
tion. 

Etiology and Pathology.— Heredity, overeating, sedentary habits, 
hot, moist climates are predisposing causes. Exciting causes are especial- 
ly the eating of fat-making food, excessive use of alcohol and insufficient 
exercise. Obesity may follow the menopause or an infectious disease. 
Osteopathic lesions are frequently found in the upper and middle dorsal 
region. These probably are causes of a disturbed metabohsm. An 
excessive diet of starches and sugars will indirectly act as a fat producer. 
In young people the possibihty of hypopituitarism should be considered. 
Lesions of the upper cervical, in these cases, are frequent. 

Pathologically, adipose tissue is deposited throughout most of 
the tissues. Usually the abdomen is encumbered with a large amount. 
Passive congestion probably favors the deposition of fat, for in cases of 
pendulous abdomen, simply drawing the abdomen in and up and the pa- 
tient, through voluntary effort, keeping it up, will frequently cause ab- 
sorption of the fat in a few days or weeks. The fat is distributed under- 
neath the skin, throughout the viscera and about the heart. The tis- 
sues may suffer from fatty infiltration, especially the heart, arteries and 
veins; also the fiver, kidneys and stomach. There is an increase of 
specific gravity of the blood. Edema occurs from passive congestion, 
due to weak heart. 

Symptoms. — The round, fat face, double chin, hanging cheeks, 
large waist, the thick, prominent, sometimes pendulous abdomen, and the 



I 



The Practice of Osteopathy 481 

bulky extremities form characteristic features. At first obesity presents 
no harmful symptoms. Usually the first troublesome symptom is in- 
creased frequency in the breathing, due to a weak and overworked heart, 
and to the fact that the motion of the lungs is hampered bj^ the heavy 
chest walls, and also by the interference with the descent of the diaphragm* 
on account of the enlarged liver. Dyspnea, passive congestion, anemia, 
poor digestion, uterine disorders, and mental inactivity are common. 
There is cardiac hypertrophy; later the heart is overlaid with fat. The 
pulse is usually frequent, but lasiy be irregular and slow. 

Treatment. — Obesity being a nutritional disease it seems but 
reasonable that alterations of the anatomical structures will produce a 
change in the proper balance of nutrition. Along osteopathic lines, de- 
rangement of tissues affecting the nerves to the digestive and lymphatic 
systems will produce obesity. In the majority of cases examined have 
been found disturbances at the sixth and seventh cervical, fourth and 
fifth dorsal and from the tenth dorsal to the second lumbar. Lesions 
at these points could readily interfere with the thoracic duct and the 
receptaculum chyH, as well as with the processes of digestion, assimila- 
tion and elimination. It is claimed that stimulation of the splanchnic 
nerves causes dilatation of the receptaculum chyli. Direct treatment 
to the abdomen and to areas of fatty deposit will aid very materially in 
absorption. 

The dietetic treatment is essential, the principle being to furnish 
less food to oxidize. Restrict fats, sugar and starches and limit the 
amount of water. Alcohol should be prohibited. Another important 
point in the treatment is exercise, which must be carried out in a sys- 
tematic way. Rules can be laid down only in individual cases and should 
be governed by the osteopath in charge. The principal effect of general 
mechanical treatment is to promote oxidation. Massage and baths are 
beneficial. The patient can do much for the abdomen by keeping it in 
and up, and walking erect. 

Scurvy 

Definition. — A constitutional disease, characterized by extreme 
general weakness, anemia, spongy condition of the gums, disintegration 
of tissue and a tendency to hemorrhages. 

Etiology and Patliology. — In comparison with former times scurvy 
is now a rare disease. Lack of fresh vegetables or their substitutes, over- 
crowding, dampness, bad hygienic surroundings, and prolonged fatigue 
under depressing influences are the predisposing causes. Arctic explor- 
ers have shown that fi-esh bear's meat and bear's blood are a preventative. 



482 The Practice of Osteopathy 

There are extravasations of blood into the skin, muscles and mu- 
cous membranes. Hemorrhages may occur in the internal organs, es- 
pecially the kidneys and liver, and in the serous membranes. The gums 
are swollen and spongy. The teeth decay. The spleen is soft and en- 
larged. Parenchymatous degeneration of the heart, liver and kidney is 
fi-equent. Ulcers occasionally occur in the skin and bowels. The blood 
is thin but there is no leucocytosis. 

Symptoms.— The disease is usually slow in development. The 
general manifestations of anemia with debihty are among the first 
symptoms. The gums are swollen, soft and spongy, they bleed easily 
and in severe cases there is ulceration. Petechial spots appear upon the 
body. Subcutaneous ecch3rmosis occurs, first on the legs, then on the 
arms and trunk. The eyes and face are swollen; the patient appears as 
if he had been bruised. Hemmorrhages from the mucous membrane fre- 
quently occur. The temperature is usualty normal. The pulse is small, 
feeble and frequent; sometimes irregular and slow. The appetite is 
impaired and constipation is present at first, as a rule, although this may 
be followed by scorbutic dysentery. 

Diagnosis. — The disease is readily recognized when several cases 
occur together. It is somewhat hard to recognize in isolated cases, and 
to be able to distinguish it from certain forms of purpura. The etiology, 
the gingival changes and the hemorrhages usually decide the diagnosis. 

Prognosis. — Scurvy being a disease due to malnutrition, it is neces- 
sary to remedy such condition by attention and correction of the faults 
producing it. Hygienic surroundings and a wholesome diet will do more 
in curing the disease than anything else. An out-door life and good ven- 
tilation with anti-scorbutics, as fruit juices, especially lemons and oranges, 
fresh vegetables, (onions, potatoes, etc.) and fresh milk, are necessary. 

It is held by Garrod that scurvy is caused by an absence of potash, 
for a deficiency of potassium salts is found in the blood. The anti- 
scorbutics named above contain potash. A careful treatment along the 
splanchnics would help to improve the appetite and digestion. Treat 
the gums and ulcers according to surgical indications. 

Infantile Scurvy 

Scorbutus 
This form usually follows the prolonged use of condensed milk, 
sterilized milk or proprietary foods for children. The disease occurs 
during the first two years of life, Ijut it is most common from the seventh 
to the fourteenth month. 



The Practice of Osteopathy 483 

It develops rapidly. Joint pains, anemia and irritability are early 
symptoms. The child is pale, has a muddy complexion and may show 
signs of rickets. The gmns may be soft and spongy. There is tenderness 
and pain on motion. There may be hemorrhages under the skin. The 
lower limbs are drawn up and motionless. The bones become thickened 
from sub-periosteal hemorrhage, and there is apt to be softening be- 
tween the shaft and epiphysis. The back and legs become very weak. 
The lesions are usually symmetrical. The temperature is variable. 

Treatment. — The treatment of scurvy in children consists in, 
first, omitting all proprietary foods and substituting fresh cow's milk, 
meat juice, strained gruel and a moderate quantity of fresh orange or lem- 
on juice. Under this treatment, cases that have not progressed too far 
will promptl}^ recover. 

Northrop says: ''It is a significant fact that the country which fur- 
nishes most of the Kterature on scorbutus in children is the same which 
is posted from end to end with advertisements of proprietary foods." 

Purpura 

Purpura is a symptom rather than a disease. It is characterized 
by extravasation of blood into the skin and bleeding from the mucous 
membranes, irrespective of direct injury. These extravasations do not 
disappear upon pressure and vary greatly in size. They may be small, 
(petechiae) or large (ecchymoses) . They are bright red and gradually 
become darker. Clotting of normal blood requires three to five minutes, 
purpuric blood, ten to fifteen minutes. 

It is a symptom of infectious diseases, as in pyemia, septicemia, 
mycotic endocarditis, typhus fever, smallpox, etc. Toxic, as produced 
by venomous snake bites and by certain medicines, as copaiba, mercury, 
quinine, iodides and others in overdoses. Cachectic purpura may 
be observed in cancer, tuberculosis, Bright's disease, scurvy, etc. In 
senile purpura the spots are generally confined to the extremities. Id 
certain nervous diseases, bleeding spots appear on the skin, as in tabes, 
myelitis and severe neuralgia. Mechanical purpura is seen in venous 
stasis; this is rare. 

Purpura simplex affects only the skin. It occasionally follows 
attacks of infectious diseases. The spots are found upon the legs, more 
rarely upon the trunk and arms. Articular pains may or may not occur. 
Fever is seldom present. I;0ss of appetite, diarrhea and slight anemia 
may be manifested. The duration is one to four weeks. 

Purpura rheumatica is a much more serious affection, character- 
ized by multiple arthritis of rheumatism. Seldom seen under five years. 



484 The Practice of Osteopathy 

and lasts about two weeks. The joints are swollen and painful and the 
temperature rises to 101 and 103 degrees F. The amount of edema varies 
greatly and occasionally it is quite excessive. In addition to the pur- 
pura there is usually urticaria. Henoch's purpura is seen most fre- 
quently in children and is characterized by severe gastro-intestinal dis- 
turbances as pain, vomiting and diarrhea, hemorrhages from the mucous 
membranes and acute enlargement of the spleen, in addition to the symp- 
toms already named under the foregoing form. There is some danger 
of hemorrhage into the kidneys. 

The disorder of purpura hemorrhagica is usually associated with 
rheumatism, malaria and other infectious diseases. This is the most 
serious form of purpura. It is most commonly met with in delicate girls 
during early life; but it may occur at any age and in the most robust 
of either sex. Fever, weakness, vomiting and diarrhea are the early 
S3anptoms. After a couple of days of languor and weakness, purpuric 
spots appear upon the skin; and bleeding occurs from the mucous mem- 
branes and may cause profound anemia. Hemorrhages into the inter- 
nal organs occur. Favorable cases recover in ten days or two weeks. 
Others may end fatally. Care should be taken not to confuse the disease 
with scurvy. 

Treatment. — In the treatment of purpm-a the disease from which 
it develops should receive due attention. Occasionally there is danger 
of overlooking the primary disease and treating some symptoms of the 
disease, although it is true that sometimes an important symptom is 
nearty all that is manifested. Outside of treating the conditions under 
which purpura arises, general measures should be considered, as a nutri- 
tious diet, rest, fresh air, and general treatment of the patient so that 
normal circulation and strength may be restored. The treatment of the 
purpura locally should be such as to restore normal circulation of the part 
by removing any obstruction or irritation of the blood supply that may 
be found, by careful manipulation of the tissues. As stated the manage- 
ment of the disease under which it arises should be embraced in the treat- 
ment. In cases of hemorrhage from various organs see article under 
hemorrhage. Some cutaneous hemorrhages are best relieved by local 
manipulation. 

Hemophilia 
(Bleeder's Disease). 

Hemophiha is a hereditary condition manifested by a tendency 
to uncontrollable hemorrhage with or without injury. The usual mode 



The Practice of Osteopathy 485 

of transmission is through the female line, rather than by the male. The 
mother does not necessarily have to be a bleeder, but the daughter of one, 
in order to transmit the disease to her offspring. Atavism through the 
female alone is almost the rule. Not all the children of a bleeding family 
are afHicted; the male children are more subject to the condition than the 
female children. The tendency usually appears within the first two 
years of hfe. The families of bleeders are often large and are commonly 
healthy looking and have fine soft skins. It is claimed blondes are most 
likely to be afflicted. 

Pathologically, an unusual thinness of the blood-vessels with a 
fatty degeneration of the intima has been noted. In many cases there 
is deficient coagulability of the blood and a lessened number of leucocytes. 
Hemorrhages have been found in and about the capsules of the joints, 
and in a few instances inflammation of the synovial surfaces. The 
arteries are situated superficially, but that does not explain anything. 
The real nature of the disease has not been determined. Emotional 
excitement is a factor, consequently vasomotor disturbances may be im- 
portant. The frailty of the blood-vessels and the peculiar constitution of 
the blood preventing thrombotic formation are the two facts of importance 
that have been recognized. 

Symptoms. — Hemorrhages occur from the most trifling injuries. 
Blowing the nose may cause severe epistaxis; the extraction of a tooth 
is a frequent cause of hemorrhage; the prick of a pin, a slight cut, a scratch, 
or a blow may result in profuse bleeding. The bleeding may occur 
spontaneously from the mucous membrane of the mouth, nose, lungs, 
intestines, etc. ; or it may occur directly from the fingers, toes, back of the 
hands, and lobes of the ears. The hemorrhages may last several hours. 
As soon as checked the patients rapidly resume natural appearance 
providing the bleeding is not often repeated, thereby causing a permanent 
anemia. There may be attacks of arthritis with fever, as with acquired 
hemorrhagic tendency, closely resembhng rheumatism. 

Diagnosis. — Hereditary tendency and persistent hemorrhage from 
shght injury. 

Prognosis. — In a few cases the tendency to bleed gradually dimin- 
ishes until at last it entirely ceases. The younger the subject the more 
is it liable to prove fatal. In the majority of cases death occurs between 
the first and eighth years. After maturity the chances of an attack are 
much lessened. 

Treatment. — Memljcrs of the bleeder's family, particularly the 
boys, should be guarded against traumatic influences, and operations 



486 The Practice of Osteopathy 

of all kinds should be avoided. Out-door exercise, fresh air, bathing and 
plain nourishing food, in fact, the hj'gienic surroundings, and all food 
should be carefully watched so that the threatened subject may become 
strengthened and hardened. Marriage should be discouraged, especially 
with the daughters, as it is through them the tendency is propagated. 
Possibly, coupled with the foregoing prophylactic treatment, a stimula- 
tion of the glands of elaboration of the blood will be of service to build 
up the physical constitution of the patient. During attacks absolute 
rest and the required symptomatic treatment should be given. For 
resultant anemia the usual treatment is to be employed. 
In severe cases direct transfusion should be considered. 



I 



The Practice of Osteopathy 487 



DISEASES OF THE DIGESTIVE SYSTEM 
Diseases of the Mouth 
Stomatitis 

Definition. — Inflammation of the mouth. 

Etiology.— Chemical, mechanical, thermal or parasitic irritations; 
secondary to disorders of the gastro-intestinal tract, scarlet fever, measles 
and variola; cachexia, due to such diseases as cancer and phthisis; den- 
tition; artificial feeding; hot weather and poor hygienic surroundings are 
the most common causes. Lesions to the innervation and vascular sup- 
ply of the mouth are found, principally, in the upper cervical vertebrae, 
occasionally in the upper dorsal vertebrae and corresponding ribs. 

Varieties. — Catarrhal, aphthous, ulcerative, parasitic, gangrenous. 

Catarrhal Stomatitis 

Etiology. — Most common in infants and children. Hot and ir- 
ritating substances; secondary to diseases of the stomach, to measles, 
scarlet fever and variola; difficult dentition; alcohohc or tobacco excesses. 

Hazzard says in all cases of stomatitis "there is generally lesion to 
the bony or other tissues in the cervical region (sometimes also in the up- 
per dorsal), which deranges vasomotor control of the tissues of the mouth 
and tongue, obstructs venous return, weakens the tissues and lays them 
liable to the effects of some particular irritant, local or in the system, but 
there is, generally, lesion affecting the gastro-intestinal tract which is the 
real underlying cause of the trouble." 

Symptoms. — Diffuse, red swelhng of the mucous membrane, 
heat and pain in the mouth, increased flow of saliva, fetor of breath, rest- 
lessness and languor. In children there is a disinclination to nurse and 
a slight fever may be present. The sense of taste is blunted and there 
is commonly a bitter taste in the mouth. The neck glands are enlarged. 

Treatment. — Removal of the exciting cause is the most improtant 
point in the treatment. Good hygienic conditions must be enforced. 
The mouth should be kept clean. Wipe it out at frequent intervals with 
a soft piece of absorbent cotton and cold water. A borax solution is 
frequently used. Attention should be paid to the diet and secretions. 
Light but thorough treatment of the upper cervical region is to be given, 



488 The Practice of Osteopathy 

with careful attention to the tissues about and below the angles of the 
jaw, so that the innervation, blood and lymphatic supply may be equal- 
ized. 

Aphthous Stomatitis 

(Canker) 

This disease is characterized by little, painful, grayish-white spots 
upon the superficial layer of the mucous membrane. They consist, 
primarily, of an exudate of fibrin and wandered-out leucocytes. It is 
principally a disease of childhood. Among the common causes are diffi- 
cult dentition, disorders of digestion and uncleanhness of the mouth, 
such as neglect to cleanse the child's mouth after nursing. It may be a 
symptom of measles or of local diseases. 

Probabl}^ the innervation to the region of the Uttle grayish-white 
spots or canker is obstructed at some points by a disordered tissue. The 
lesion may be mechanical or it may arise from a disordered digestion. 
If one is able to locate such a lesion and remove it, a cure will be hastened. 
The seat of the infection is the internal surface of the cheeks, gums, roof 
of the mouth, tongue and Ups. 

Symptoms.— There is redness of the mucous membrane of the 
mouth, followed by the appearance of the vesicles with a red areola. 
Pain in the mouth and an increased flow of saliva occur. Mastication, 
deglutition, and even speaking, may be painful. This condition is 
followed by sleeplessness, [feverishness, diarrhea and fetor of the 
breath. 

Treatment. — Removal of the cause, as in other varieties of stoma- 
titis, is paramount. Give attention to the food. The milk should be 
sterilized. The disordered digestion should be corrected at once. All 
secretions must receive prompt attention. The child should be nursed 
at regular intervals. Locally, keep the parts clean and carefulty treat 
the innervation. 

Ulcerative Stomatitis 

This is a disease of children, although it may not be hmited to them, 
as it occasionally occurs in epidemics and affects all ages. It occurs 
chiefly in the families of the poor and in places where the hygienic sur- 
roundings are bad, the food poor and personal cleanliness lacking. It 
may begin as an aphthous stomatitis. Often sufferers from severe, acute 
diseases are subjects of attack. 



The Peactice of Osteopathy 489 

Symptoms. — The gums of the lower jaw are chiefly affected. They 
are at first congested, swollen and bleed readily. Pain is increased by 
mastication and deglutition, the mouth is hot, the breath fetid, the saHva 
dribbles and the digestion and bowels are disordered. The ulcers may 
appear at various points upon the cheeks, lips and tongue; the deposit 
is yellowish-gray. 

In the more severe cases the gums are spongy and the teeth are loos- 
ened. In proportion to the constitutional disturbances, fever and en- 
largement and tenderness of the submaxillary glands occur. Even 
necrosis of the bone may follow. 

Parasitic Stomatitis 

(Thrush) 

The exciting cause is a fungus known as Laccharomyces albi- 
cans. It is claimed that a catarrhal stomatitis is the soil upon which the 
fungus develops. Parasitic stomatitis is chiefly a disease of nursing 
children and is promoted by unhygienic conditions. It is seldom seen 
after ten years of age, occurring in adults only in the last stages of con- 
sumption, cancer, and severe chronic diseases. 

Symptoms. — Upon inspection there are seen numerous milk-white 
elevations. These appear first about the angles of the mouth, soon ex^ 
tending to all parts of the mouth, and in a few cases, even to the pharynx 
and to the esophagus. When removed bleeding points are left. The 
general symptoms of stomatitis are present — pain upon mastication and 
swallowing; fetid, hot breath; increased sahva; increased temperature; 
restlessness; swollen lips and disordered digestion occur. 

Diagnosis. — The microscope will remove all doubt as to the nature 
of the affection. In aphthous stomatitis the ulcers are preceded by the 
formation of vesicles. 

Prognosis. — Is favorable in the majority of cases. 

Treatment. — Hygienic measures, absolute cleanliness, correction 
of the disorders of the gastro-intestinal tract and local treatment as in 
other forms of stomatitis, is the required treatment. A boric acid solu- 
tion will be found beneficial. 



490 The Practice of Osteopathy 

SPINAL LESIONS AND THEIR RELATION TO DISEASES OF 
THE GASTRO-INTESTINAL TRACT 

Acute Gastritis, Chronic Gastritis, Gastric Neurosis, 
Gastric and Duodenal Ulcer. 

By Charles J. Muttart 

The instant relief that Osteopathy can give in acute indigestion is 
one of its outstanding achievements. It impresses the patient and his 
friends with a deep conviction of the superiority of osteopathic therapy. 
The results in these cases are not, in any sense, a matter of chance. They 
follow logically from the osteopathic viewpoint, teaching, reasoning, and 
practice. In deaHng with the manifestations of disease, such as heredity, 
onset, course, duration, subjective and objective symptoms, etc., and 
in the effort to differentiate cause from effect, and to reconstruct a mental 
picture of the sequence of cause, effect and sequelae, the osteopath has 
the advantage of binocular vision in that he recognizes two distinct 
pathologies co-operating to produce the symptom complex, syndrome or 
disease which he is called upon to treat. One pathology is to be found 
in one or more of the vertebral and rib articulations and the immed- 
iately adjacent or corresponding segments of the spinal cord. The 
other is in some one or more of the organs or tissues connected with the 
pathological segment or segments of the cord. 

The function of the joint is MOTION. — Unrestricted normal 
range of motion is essential for the normal function of all parts of the 
articulation as well as for the nutrition of the nerve mechanisms immed- 
iately adjacent. When a spinal articulation ceases to perform its func- 
tion all of its parts are more or less impaired, muscles atrophy, liga- 
ments lose their tone, and circulation to and from the spinal segment is 
interfered with because action is a large factor in promoting the flow of 
blood and lymph and maintaining normal stimulus. 

As a result of this spinal pathology, internal organs and tissues, sup- 
plied by nerves arising in the segment that is in lesion, will be variously 
disturbed in their function. 

Dr. Carl P. McConnell says: ''My observation of lesioned animals 
so far as the digestive organs are concerned is that the lesion affects the 
reflexes of and through spinal and sympathetic ganglia so that the vaso- 
motors arc involved with a consequent hyperemia of the submucous 
coat. This means involvement of the endothehal layer of the blood- 
vessels, diapedesis, derangement of the secretory function and dis- 



The Practice of Osteopathy 491 

turbance of the motor mechanism, all of which lead to functional upset 
and disturbance." 

The dominant part played by the osteopathic lesion as a causative 
factor in acute and chronic diseases of the alimentary canal becomes in- 
creasingly evident as cHnical observation and laboratory research permit 
a more thorough appreciation of the anatomy and physiology of the 
parts involved. The abnormal stands out more clearly from the normal. 
Finally, the task of restoring normaUty is becoming a clear-cut problem 
to which the correction of the osteopathic lesions furnishes an almost 
complete solution. 

The normal ahmentary canal transports food, macerating it, mixing 
it, and treating it with various chemicals and enzymes on the way, break- 
ing it down physically and chemically, and absorbing from it such end- 
products as are needed to maintain metabohsm. The abnormal ali- 
mentary tract may be at fault in any of these functions. This dehn- 
quency is generally traceable to a mechanical origin. Correction of 
the mechanical deviation is followed by restoration of normal function 
except in cases where extensive tissue changes have occurred. 

Thorough mastication is essential to good digestion. Any dental 
defects or deficiencies should be corrected. The tentporo-mandibular 
articulation should be examined, and full free motion restored if lack- 
ing. The muscles on the affected side are softer than on the sound side. 
Tonic spasm rigidly closes the mouth. It may be due to tetanus, caries 
of the lower teeth, cutting of the lower wisdom tooth, or other irritations 
to the sensory branches of the inferior maxillary nerve. There is enough 
space back of the wisdom teeth to pass a catheter to administer food. 

The tongue assists in mastication and deglutition and is the seat 
of most of the nerves of taste. The hypoglossal nerve, which supplies it, 
leaves the skull through the anterior condyloid foramen and may be 
impinged there or lower in its course. Lesions of the occiput and 
upper cervical vertebrae and obstructions to the lymphatic drainage 
at the angle of the jaw may cause pressure on this nerve and cause dis- 
turbances in the movements of the tongue, atrophy, swelling, etc. Swell- 
ing may be due also to endocrine disturbance, constitutional diseases, 
anemia, glossitis, local irritants, injuries, etc. Pressure may be made 
on the hypoglossal nerve behind the angle of the jaw. 

The special sense of taste plays an important role in normal 
digestion. The hngual nerve supphes the anterior two-thirds of the 
tongue with taste. The sense of taste may be lost, impaired, perverted 
or otherwise abnormal. 



492 The Practice of Osteopathy 

The sense of smell plays an important part in om- appreciation of 
flavors, and when it is impaired by colds, adenoids, or other affections 
of the nose or pharjmx, the sense of taste is measurably impaired. Nor- 
malization of nose and pharynx restores the sense of taste in such 
cases. Impairment or loss may also be due to lesions of the chorda tym- 
pani, or glosso-pharyngeal nerves. Lesions of the mandible, hyoid, 
occiput or upper cervical nerves, parotid disease or obstructed lymphatic 
drainage behind the angle of the jaw may cause pressure directly or in- 
directly on the glosso-pharyngeal and chorda tympani nerves. Per- 
version of taste occur in pregnancy, hysteria, epilepsy and insanity. 

Foul taste, fetororis in the mouth is frequent in pneumonia, ty- 
phoid fever, peritonitis, septicemia and other severe fevers; also after 
ingestion of pungent foods or strong drugs; in constitutional diseases; as 
a result of inattention to oral hygience, excessive smoking, mouth breath- 
ing at night, furred tongue, etc. It clears up on removing the cause. 

Furred tongue occurs in gastritis, fevers, and a variety of other con- 
ditions. The fur is composed of broken down epitheUum which would 
normally be removed by friction with solid food. When none is taken, 
the fur accumulates. When blood or hematin becomes mixed with the 
broken down epithelium, the fur is brown. Ordinarily it is white. A 
clean red tongue is frequently found in hyperacidity. It is probably 
due to vasodilatation due to hyperactivity of the autonomics or inhibi- 
tion of sympathetics. The sympathetic supply is from the superior 
cervical ganglion. It may be affected by lesions of the occiput, atlas, 
axis and third cervical vertebra, of the hyoid, by anterior cervical muscu- 
lar contractures, by obstruction to venous and lymphatic drainage and 
blood supply. Correction of the lesions named and normahzation of the 
other structm-es involved will usually restore the tongue to normal con- 
dition. 

The salivary glands have a two-fold innervation. The thin, full, 
watery, salty secretion is produced by activity of the cranial autonomic 
fibers; the sparse, viscous secretion containing the organic elements, 
ptyalin, etc., is produced by the sympathetics. The sympathetic 
nerve supply is from the middle and superior cervical ganglia and can 
be disturbed by lesions affecting them as mentioned above. The secre- 
tion of ptyahn may be disturbed by any lesion from the fifth dorsal up. 

It must not be forgotten that a posterior occiput draws the super- 
ior cervical ganghon back against the axis and third cervical with just 
as much pressure as is exerted by an anterior atlas or third cervical. 
This pressure or stretching tends to inhibit it, preventing vasoconstric- 



The Practice of Osteopathy 493 

tion and permitting vasodilatation of the internal carotid artery and 
its branches and congestion of the parts suppUed, mid-brain, cerebrum, 
etc. 

If, for any reason, the venous drainage from the lateral sinus into 
the internal jugular vein, or the ebb and flow of the crebrospinal fluid 
between brain and cord, is reduced or hampered, an extra burden is 
thrown on the cerebral veins and sinuses, and the intra-cranial pressure 
is raised at each heart-beat, ultimately producing pressure on the menin- 
ges and causing violent headache over the fifth and tenth cranial nerves 
which supply the meninges with sensation. These nerves are inti- 
mately connected with the digestive system. Any increase of intra- 
cranial pressm'e causes increased irritabiHty and hyperactivity of the 
cranial nerves, many of which are concerned with various functions of 
the digestive system. Moreover, the nuclei of these nerves He on the 
floor of the fourth ventricle which is suppHed mainly by the vertebral 
arteries and the basilar artery. Lesions of the cervical vertebrae affect- 
ing the plexus on the vertebral artery or filaments to it from the upper 
parts of the cervical ganghated sympathetic cord, may impair the blood- 
flow through the vertebral arteries and cause similar increased irrita- 
biHty of the nerve-cells in the medulla, mid-brain and cerebellum. Such 
disturbance is reflected in awkward movement, hyperesthesia, and symp- 
toms due to increased irritabiHty of the autonomic nerves such as slow 
pulse and respiration, watering of the mouth, hypersecretion and hyper- 
motility of the gastro-intestinal tract, rapid digestion and poor assimila- 
tion, vasodilatation, impoverished blood, and so through a vicious cycle 
back to still greater impairment of nutrition to the nerve-cells within the 
cranium. Until the lesions are corrected, the condition becomes pro- 
gressively worse till exhaustion occurs. 

Ordinary medical hygiene can do little or nothing. The palHative 
remedies employed simply mask the symptoms, or actually accelerate 
the destructive process. Lesions that irritate the cervical sympathetics 
would cause vasoconstriction and give rise to opposite symptoms, name- 
ly, cerebral ischemia, decreased flow of saHva, atony of stomach, lack of 
digestive juices, sluggish intestinal peristalsis, rapid pulse and respira- 
tion, etc. Correction of the lesions and restoration of normal blood- 
supply and drainage to the brain and removal of anj^ lesions tending to 
inhibit the sympathetics from the fifth dorsal up, will usually in a short 
time restore the activity of the saHvary glands to normal. The otic 
and sphenopalatine gangHa can be disturbed by abnormal conditions 
within the pharynx. These must be corrected when found. 



494 The Practice of Osteopathy 

Deglutition, or swallowing, is a very rapid, highh^ complex move- 
ment. It takes not more than a second for the food to cross the pharynx. 
The soft palate and larynx are raised to close off the air-way, making 
the food-way practicallj' continuous for the second needed to complete 
the transfer of the food across the air-way. The tongue is pressed against 
the roof of the mouth and the mylohyoid contracts vigorouslj^ and 
shoots the bolus of food across the pharynx. Bolting. the food leads to 
serious digestive disturbances, not the least of which is the loss of the 
normal reflex which prevents swallowing unprepared food. When lost, 
this reflex can be restored by thorough mastication for three or four 
months. 

The voluntary part of swallowing is performed by the motor por- 
tion of the fifth cranial and the hypoglossus. The involuntary part 
involves afferent impulses over the superior laryngeal and efferent im- 
pulses over the inferior laryngeal. The levator palati which raises the 
soft palate is probably supplied by the spinal accessory nerve through 
the pharyngeal plexus. This nerve can be affected by lesions of the 
occiput, atlas, mandible and hyoid, and by any obstruction to lymphatic 
drainage which increases pressure behind the angle of the jaw. In paraly- 
sis of the levator palati, as af terdiphtheria or other peripheral neuritis, 
fluids regurgitate through the nose during the act of swallowing. The rais- 
ing and closing of the larynx is accompHshed by the superior and recur- 
rent laryngeal nerves by way of the pharyngeal plexus. Pain in swal- 
lowing is generally due to some inflammation or infection of the tonsil 
or phar3^nx. This does not occur when everything is normal from the 
fifth dorsal up. 

The second and third stages of swallowing occur in the esophagus. 
The esophagus receives esophageal branches from the vagus, carrying 
autonomic fibers which contract its longitudinal muscles and dilate its 
arteries. It also receives sympathetic impulses from the plexus on the 
arteries which supply it. These sympathetic impulses convey vaso- 
constriction and constriction of the circular muscles of the esophagus. 
Anj^ lesion from seventh cervical to ninth dorsal might affect the esopha- 
gus; probably fifth dorsal is the most nearly specific, as the heartburn 
which results from regurgitation into the esophagus is usually locahzed 
there. 

Lesions of the upper six dorsal vertebrae interfere with digestion and 
nutrition in another vital way by reducing the activity of the lungs and 
consequent intake of oxygen into the system. If there is not sufficient 
oxygen to oxidize the pi-oteins to amino-acids there will be harmful pro- 



The Practice of Osteopathy 495 

ducts left for the tissues to neutralize. Lesions of the third, fourth and 
fifth cervical affecting the phrenic may have a like effect. Sub-oxida- 
tion must be noted when present and treated by removing lesions affect- 
ing respiration, b}^ deep-breathing exercises, and by diet rich in the needed 
mineral salts, and properly balanced. An improperly balanced diet 
changes the structure of the tissues and amounts in effect to an osteo- 
pathic lesion which causes disturbed function. It must be searched 
for, found if present, accounted for, corrected and kept corrected to ob- 
tain maximum therapeutic results. 

The stomach, intestines and rectum are intimately related with 
the other abdominal viscera. 

It will therefore be readily seen that any disturbance of the hver, 
gall-bladder, pancreas, spleen, duodenum, pleura or peritoneum will 
disturb the function of the stomach, and that anj^ disturbance of any 
organ will disturb the function of the intestine. In fact, chnically, it 
would seem that the majority of cases can be accounted for by the lesions 
found, the stomach or intestinal disturbances which are regarded as 
reflex from some other organ, being in reaHtj^ caused by the same lesion 
as disturbed the organ which first manifested disturbance. 

Going more deeply into the nature of the mechanism whereby symp- 
toms of gastro-intestinal disturbance are produced, we find that the aU- 
mentary tract has an ingenious conveyer mechanism with a number of 
sphincters. These are operated by intrinsic sympathetic or myenteric 
nerves, called plexuses of Meissner and Auerbach. In conveying food, 
impulses are passed from one portion of the tract to the next over these 
myenteric arcs. Normally the peristaltic movement is always forward 
because the point of highest irritabihty is at the proximal end. There 
is an exception to this rule in the ascending colon, where antiperistalsis 
occurs normally. When the irritability of a distal point of the ali- 
mentary tract becomes greater than the more proximal points, an anti- 
peristaltic wave is set up causing vomiting. The myenteric activities 
are regulated by the autonomic impulses over the vagus, and by the 
sympathetic impulses over the splanchnic nerves. The autonomics 
contract the longitudinal muscles, dilating and shortening the tube. 
They also stimulate secretion of digestive juices and fluids and mucus 
and dilate the blood-vessels. The sympathetics contract the circular 
fibers and sphincters, narrowing and lengthening the tube, retarding 
the food, inhibiting the secretions and constricting the blood-vessels. 
The myenteric reflexes can continue after the vagi and splanchnics are 
cut. The vagi simply stimulate them and the splanchnics inhibit them. 



496 The Practice of Osteopathy 

The pathways are from the coeliac plexus where the vagi and splanch- 
nics meet with various other plexuses on the arteries and following the 
courses of the arterial supply to the minutest parts of each organ. Each 
cell is surrounded by nerve fibers. Visceral-afferent fibers over both 
vagi and splanchnics convey impulses to the cord segments and me- 
dulla which modify the systemic blood-supply, drawing blood from the 
head and surface by constricting their arteries during digestion and filling 
the abdominal arteries. If opposite impulses should be received drawing 
blood away from the abdominal arteries, digestion would be interfered 
with. Any lesion or other condition causing hyperirritabihty or over- 
stimulation of the vagus will result in overstimulation of the myenteric 
nerves, with vasodilatation, hypersecretion, contraction of the longitudinal 
coat, widening and shortening of the digestive tube, sluggish peristalsis 
but rapid movement of food through the sphincters, incomplete diges- 
tion and undernourishment. Inhibition of the splanchnic nerves will 
produce a like result. The opposite condition would come about as a 
result of inhibition of the impulses over the vagus to the myenteric nerves, 
or of overstimulation of the splanchnic nerves. 

Inhibition of the splanchnic nerves may be secured by extreme flex- 
ion of the spinal column. This raises the cord in the spinal canal, length- 
ens it, stretches or draws on the nerve roots and vessels, squeezes the fluid 
out of the cord, and inhibits the splanchnics in two ways, first by a partial 
anemia or ischemia of the cord, and secondly by direct traction of the 
visceral afferent fibers in the posterior and anterior roots. 

Conversely, stimulation of the splanchnic nerves may be secured by 
complete extension of the spinal column. This lowers the cord in the 
spinal canal, shortens it, releases the strain on the nerve roots and ves- 
sels, flushes the cord with blood, and tones up the sympathetic impulses 
in two ways, first by increasing their relative and absolute nutrition, 
through richer supply of richer blood, and secondly by releasing the 
nerve roots from. strain, permitting free entry of afferent impulses over 
the posterior roots, and free exit of visceral-efferent impulses over the 
anterior roots. 

Any lesion, inasmuch as it limits or alters the normal motion in a 
joint, produces an exaggeration or diminution of the normal spinal curves, 
and more or less lateral curvature. The altered equihbrium thus pro- 
duced affects the viscera in three ways: 1. Mechanically, by pressure, 
gravity, altered position of ribs, vertebrae, diaphragm, etc. ; 2. Reflexly, 
influence on nerves to and from affected segment; 3. Directly, by inter- 
ference with nutrition of nerve-cells by hyperemia or ischemia. 



The Practice of Osteopathy 497 

There is always a functional kyphosis in visceroptosis or splanch- 
noptosis. The nerves in the cord are inhibited. The skeletal muscles 
are hypotonic, allowing the functional kyphosis to occur, and the viscero- 
motor nerves are inhibited, allowing the abdominal viscera to become 
hypotonic and sag out of place within the abdominal cavity. The ribs 
are held up by the cervical fascia, and the abdominal muscles are held up 
by the ribs. The hypotonic condition extends to intercostals and ab- 
dominal muscles, with the result that the abdominal muscles are unable 
to play their part in maintaining the viscera in their proper places. The 
contraction or tonus of the abdominal muscles, the external and internal 
oblique, transversahs, rectus abdominis, diaphragm and levator ani, 
maintain the viscera firmly in position. It is only when the muscles of 
the abdominal wall have lost their tone that any strain or weight is thrown 
on the peritoneal and vascular supports. The inhibition of the restrain- 
ing sympathetic impulses via the splanchnic nerves, allows hypersecre- 
tion and hypermotility of the ahmentary tubes and further compHca- 
cates the clinical picture by a coKcky diarrhea or spastic constipation. 

There are eight sphincters of circular unstriped muscle in the ali- 
mentary tract. Inhibition of sympathetic supply or increased auto- 
nomic supply causes sphincter insufficiency, overstimulation by sympa- 
thetic impulses or an insufficient supply of balancing autonomic im- 
pulses causes sphincter spasm, stasis, vomiting, fermentation, putrefac- 
tion, auto-intoxication. At each of these sphincters food is held back 
and controlled tiU the proper time has elapsed and the proper chemical 
environment is prepared for it in the next portion of the tract. Normal 
function of these sphincters is absolutely essential to normal metab- 
oKsm and nutrition. The upper esophageal sphincter controls the en- 
trance to the esophagus; the cardia controls the entrance to the stomach, 
the pylorus controls the entrance to the duodenum, the X-Ray shows 
a duodenal sphincter that controls the entrance of food into the jejunum. 
Here the food enters the long tract of the jejunum and ileum which 
measures twenty-five feet when the longitudinal muscles are relaxed and 
the circular muscles tonic, and which a short time later may measure only 
fifteen feet when the longitudinal muscles are contracted and the circular 
are relaxed. This section ends at the ileo-cecal valve, which controls 
the entrance of food into the cecum. There is the mid-colic sphincter 
about the junction of the proximal third with the distal two-thirds of 
the transverse colon, and the. recto-colic sphincter which controls the 
passage from the sigmoid to the rectum. The rectum ends in the in- 
ternal sphincter ani. There is some evidence of a ninth sphincter, the. 



498 The Practice of Osteopathy 

mid-gastric at the point where the peristaltic waves of the stomach be- 
gin. Absorption takes place mostly from the ilemn and jejunum and 
it is worthy of note that four of these sphincters hold the food up on its 
way into this part of the tract, and four of them hold it back on its way 
out. Any lesion m.Siy affect one or other of these sphincters. It is be- 
lieved that antiperistalsis from the mid-colic sphincter to the cecum dur- 
ing digestion is normal permitting more complete absorption of nour- 
ishment. Yet here, after absorption is complete, and at all times else- 
where in the ahmentary tract, peristalsis is normally forward because the 
point of liighest irritabihty is at the upper esophageal sphincter and the 
irritabihty decreases as the tract is further from the esophagus. 

When the splanchnics are inhibited and the vagus autonomic im- 
pulses are normal or increased, the intestinal sphincters from the py- 
lorus down may all be incompetent, so that food passes along too rapidly 
to be properly digested and absorbed. This results in undernourish- 
ment. 

Any lesion anywhere in the body will affect peristalsis. It be- 
gins at the lower third of the stomach where it joins the pyloric portion 
and goes forward to the internal sphincter ani, being modified in its course 
by local conditions. Compensation may be estabhshed. Many cases 
of diarrhea and constipation are thus to be accounted for. Diarrhea 
is a symptom due to vasodilatation, hypersecretion and relaxation of 
the circular muscles especially at the sphincters. When these three 
factors are cleared up by correction of the lesions and hyper-extension 
of the spine, the diarrhea stops unless some other factor is at work to 
irritate the myenteric nerves or to excite the autonomics or inhibit the 
splanchnics. Lesions from the sixth dorsal down are usually accom- 
panied at first by some diarrhea, which afterwards becomes constipa- 
tion, through loss of tone in the longitudinal muscles especially in the 
distal part of the colon. In these cases, correction of lesions, and ex- 
treme flexion of the lower dorsal and lumbar spine will give relief while 
the body is returning to normal. 

When gastric digestion begins, simultaneous action is set up in the 
ileum. When disease of the cecum, appendix or ascending colon is 
present, there is contraction of the ileo-cecal valve causing stasis of the 
lower ileum and disturbed or retarded action of stomach and duodenum. 
These reactions are brought about by impulses to and from the myen- 
teric plexus. The sympathetic and autonomic nerves affect the motor 
system of the alimentary tract not directly but through the myenteric 
or Auerbach's plexus. 



The Peactice or Osteopathy 499 

The external sphincter ani muscle is supplied by the pudendal 
nerve from the third and fourth sacral segments. It is in a state of tonic 
contraction, and having no opposing muscles keeps the anal orifice closed. 
The autonomic supply to the longitudinal muscles in the descending colon 
and rectum is from the second and fourth sacral. Inhibition here will, 
therefore relax the longitudinal muscles and external sphincter and per- 
mit free peristalsis in the descending colon and rectum. Pelvic disturb- 
ances may afi^ect these nerves, or pressure due to visceroptosis, etc. The 
circular muscles of this section are supplied from the lumbar cord. They 
may be affected in any lumbar lesion, with the end result of spastic con- 
stipation by reason of a shortened markedly distended descending colon, 
sigmoid and rectum, and little peristalsis because of inhibition of the cir- 
cular fibers, and contraction of the external sphincter ani. 

The fundus of the stomach, lying in the left dome of the diaphragm, 
always contains a cushion of air which supports the left dome of the dia- 
phragm, as the convexity of the liver supports the right. Normally the 
air is regulated and causes no symptoms. A lesion, usually of the mid- 
dorsal or lower dorsal segments may inhibit the circular fibers and permit 
distension, which becomes enormous when the pylorus is obstructed. 
The shortness of breath, palpitation of the heart, etc., accompanying this 
distension are probably due to pressure on the heart and lungs from 
which the stomach is separated only by the diaphragm. 

Eighth, ninth and tenth dorsal lesions play a large part in peptic ul- 
cers by permitting hyperemia, hypersecretion, and lowered vitahty of 
the mucosa, and pyloric incompetence or spasm, because the pylorus, 
pyloric end of the stomach and first part of the duodenum get their chief 
sympathetic supply from the ninth and tenth dorsal segments of the cord. 
The tenth vertebra is more freely movable than the higher dorsal joints 
and is therefore more frequently in lesion, which helps to account for the 
greater frequency of duodenal ulcer. 

The main sympathetic supply to the appendix seems to be derived 
from the eleventh dorsal segment. The appendix has the same motor 
and secretory mechanism as the rest of the ahmentary tract but is richly 
supplied with lymphoid follicles. One of the twigs from the eleventh dor- 
sal nerve pierces the rectus muscle to supply the skin at McBurney's 
point, thus explaining the great frequency of pain and cutaneous hyper- 
algesia at this situation in appendicitis. Lower dorsal and upper lum- 
bar lesions are unquestionably causes of many cases of appendicitis 
and other obscure diseases traceable to appendicitis. Correction of 



500 The Practice of Osteopathy 

these lesions has restored the appendix and related structures to nor- 
mahty in hundreds of cases. 

Sensory reflexes are shown in hyperalgesia and pain or tenderness in 
the abdominal skin and muscles and the parietal layer of the peritoneum 
from the ensiform cartilage to the pubes in an area extending about two 
inches on each side of the mid-hne, corresponding to the distribution of 
the twigs of the lower six thoracic nerves which supply sensation to this 
region. Esophageal disturbance at the cardia causes pain in the re- 
gion supplied with sensation by the fifth and sixth dorsal, near the ensi- 
form. Gastric derangement causes pain midway between the ensi- 
form and umbilicus, which radiates to the left, in the area supphed by 
the eighth dorsal. Hepatic disturbance causes pain on the right of 
the median line, radiating to the right in the sensory distribution of the 
ninth dorsal. Intestinal pain is located in the sensorj^ distribution of 
the tenth dorsal nerve in an oval area around the umbihcus. Pain 
due to duodenal ulcer is sharply localized at a point about an inch or 
two above and to the right of the umbihcus where twigs of the tenth 
dofsal nerve come to the surface. This point corresponds closely to the 
normal position of the underlying duodenum, thougli the duodenum may 
be displaced, and the sensitive spot remain at the same point. The pain 
from fundal gastric ulcer or carcinoma is usually locaHzed sharply 
about an inch or two to the right of the median line mid-way between 
the ensiform and umbilicus, at the spot where the twigs from the eighth 
dorsal nerve pierce the rectus and come to the surface. In the disease 
of the pylorus, reflex pain is lower; of the cardiac end, higher. The 
reflex pain at McBurney's point in appendicitis has been referred to, but 
it must be borne in mind that pain from disturbance in the colon also 
shows in the sensory distribution of the eleventh dorsal nerves midway 
between the umbilicus and pubes. Pain may also be referred to areas 
supphed in the back by the corresponding segments. These reflex pains 
can usually be stopped by inhibiting along the spine corresponding to 
the sensory area affected. This reduces the impulses entering the pos- 
terior roots and lowers the irritabihty of the segment. 

The motor reflexes from gastro-intestinal disturbances result in 
muscular contractures of spinal, abdominal and other muscles supplied 
by motor nerves arising in the anterior horn of the segment which inner- 
vates the part of the viscus that is affected. Stomach, liver, gall-gladder 
pyloric and duodenal disturbances cause increased tone, contraction, 
contracture and rigiditj^ of the rectus muscles above the umbihcus, for 
instance, and the other viscera contract it in lower portions. More 



The Practice or Osteopathy 501 

important are the extreme contractures of the musculatm-e of the back 
which is suppHed by the segments which supply the affected part of the 
viscus. These contractures produce some distortion and loss of motion 
in spinal joints and thereby produce the same effects as primary lesions, 
causing widespread disturbance which persists until the spinal muscu- 
lature is normalized. In colic, the lumbar segments being involved, 
there is marked contraction of the ilio-psoas which causes the char- 
acteristic drawing up of the thighs on the abdomen, while the extreme 
contraction of the rectus abdominis draws the thorax down. 

Most persistent vomiting may arise reflexly from other organs as 
in so-called biliousness, jaundice, pregnane}^, brain affections, appendi- 
citis, onset of acute infectious diseases, alcohoHsm, sea-sickness, cohc, 
hernia, intestinal obstruction, migraine, shock, and anesthesia. Irrita- 
tion of any sensory branch of the vagus or of nerves which connect with 
it in the medulla, or reflexly from consciousness via the cerebral cortex, 
as in the case of nauseating sights, smells, tastes, as well as irritation 
from any viscera innervated from the sixth dorsal down, may over- 
stimulate the corresponding efferent nerves going to parts of the ah- 
rnentary tract supphed by that segment, increase its irritability and start 
antiperistalsis. Similarly disturbances in almost any viscus may reflex- 
ly disturb the normal balance between sympathetic and vagal autonomic 
stimuU resulting in hypersahvation, hyperchlorhydria, pylorospasm, 
distension, gastric atony, gastrosulcorrhea, enterocolitis, spastic con- 
stipation, achyha, or coKcky diarrhea. In these cases, the derange- 
ment of the viscus reflexly disturbs the aHmentary tract through central 
nerve connections. Correction of the primary trouble is followed by re- 
moval of the reflex symptoms. In this connection it is important to 
note that the visceral reflex symptoms may arise from irritation of the 
ahmentary tract by improper diet, poor cooking, or wrong combinations. 
Carbohydrates digest quicker than proteins, and these more rapidly 
than fats. Food is handled by the fundus in the order in which it was 
swallowed. If the fats are swallowed first, the starches may be held up 
for five or six hours, subjected to the acid stomach secretions and al- 
lowed to ferment causing distension, which reflexly produces a variety 
of symptoms. 

Mental exertion, strong emotions, heavy physical exertion, inter- 
fere with the function of the alimentary tract and set up disturbances 
in the balance of sympathetic and vagal autonomic impulses, through 
the nervous reflexes via the cortex, and through the demand for blood, 



502 The Practice of Osteopathy 

which impoverishes the abdominal circulation at a time when it needs 
all the blood it can get. The ischemia produced in this way has about 
the same effect as ischemia produced by a spinal lesion. Conversely, 
disturbances of the alimentary tract produce profound changes in char- 
acter and personaUty, by reflexes to the cerebral cortex causing dullness 
of perception, in all the senses, poor memory, sluggish thought, erratic 
judgment, irritable disposition, fear, worry, lack of ambition, indecision, 
lack of energy, vacillation, and finally a psychosis in which manic-de- 
pressive symptoms are balanced by paranoiac sjTxiptoms. 

The alimentary tract is so intimately bound up with the whole 
stream of vital activity, whether vegetative, sensorimotor, or psychic, 
that any disturbance of body or mind is Ukely to affect it in some part, and 
conversely any disturbance of the alimentary tract is bound to affect all 
the rest of the body and the mind. A satisfactory classification of its 
diseases is therefore difficult to make, but the one here adopted is prob- 
ably the best for the purpose. The early stages of gastro-intestinal dis- 
eases are often so similar that it is nearly impossible to differentiate 
them with certainty; the classification is therefore based on the clinical 
picture and pathology of advanced stages. Fortunately, with the ex- 
ception of cancer, diseases treated in the early stages usually clear up 
when the lesions are corrected, and the necessary attention given to the 
other causative factors present. 

Acute Gastritis 

Acute dyspepsia is one of the frequent disorders of the stomach. 
It may occur as an early symptom of an infectious disease, but very often 
it is due to some non-specific irritation. The usual exciting causes are 
errors of diet, over-indulgence in improperly cooked and highly seasoned 
food, or food that has been spoiled, such as meat, fish and milk, or over 
or under ripe fruit. Food that is either too hot or too cold may develop 
an attack. Alcohol is a common cause in those not accustomed to its 
use. Overuse of tobacco may bring on an attack. Many acute "bil- 
ious" attacks are brought about by some mental shock or excitement at 
the time of taking food, for it has been shown by the researches of Pawlow 
that both gastric motion and secretion are altered by mental irritation 
during digestion. 

Unquestionably osteopathic lesions of the splanchnics and vagi are 
important predisposing factors. These lesions produce a lowered re- 
sistance of the tissues, which will frequently explain whj^ certain excit- 



The Practice of Osteopathy 503 

ing factors that will initiate an attack in one individual will not do so in 
another. A healthy mucosa will not be so readily irritated by either 
indigestible or partly decomposed food. 

Osteopathic experimental work reveals that the vertebral and rib 
lesions readily affect both the spinal nerves and the sympathetic ganglia, 
which is followed by vasomotor and trophic disorder to the mucous and 
submucous coats of the stomach, as shown by eccymosis and hemorrhage 
of the submucosa and beginning parenchymatous degeneration of the 
free ends of the glands of the mucosa. Upon the other hand irritation 
of the muscles from dietetic errors always causes more or less contrac- 
tion of the muscles in the upper and middle dorsal, which, in turn, may 
produce through imbalance of tension and fibrositic changes, constant 
interosseous lesions and thus be the cause of the catarrh becoming chron- 
ic. This vicious cycle phenomenon should not be overlooked. Viscero- 
motor, viscerosensory and viscerotrophic reflexes may be factors in the 
pathogenesis of the osteopathic lesion. 

Pathologically, the mucous membrane is more or less covered 
with mucus. Upon removal of the mucus the membrane is found red 
and swollen, and the epithelial cells of the glands are granular. This is 
especially noted in the pyloric area. There are minute extravasations of 
blood and hemorrhages of the mucous coat, and infiltration of the sub- 
mucous layer. 

Symptoms. — Acute gastritis occurs at all ages, so particularly in 
children care has to be taken that the attack is not the beginning of some 
infectious disease. A careful inquiry into the history, and examination 
of thevomitus will usually make the diagnosis clear. The sudden onset 
of nausea, vomiting, pain in the epigastric region referred to the back 
and head, vertigo in some cases, if the infections can be ruled out should 
leave no doubt as to the nature of the disorder. 

Other symptoms are weakness, and chilhness which later if the 
attack is severe, is followed by fever. The tongue is coated, the hps 
dry, and there may be herpes. Belching of gas, constipation in some and 
diarrhea in others, and dark colored urine are noticeable. There is ten- 
derness on palpation over both the stomach and splanchnic areas. Ex- 
amination of the stomach contents show deficient hydrochloric acid, the 
presence of organic acids, bile and undigested food, and consideral^le 
mucus. 

Diagnosis. — In young children acute gastric indigestion is common, 
though a casual gastritis is rare. In the former prostration, vomiting, 



504 The Practice of Osteopathy 

and undigested, greenish stools are noted. In some cases there is no 
fever, while in others it may range from 102 to 105 degrees. In all cases 
care should be taken, as has been stated, that the attack is not the be- 
ginning of some infectious disease. Appendicitis, acute bowel constric- 
tion, pregnancy, uremia, meningitis, gall-stone colic, and gastric crises 
of tabes dorsahs should be differentiated. Most attacks of acute dys- 
pepsia are over in twenty-four hours. The prognosis depends upon 
eliminating the cause. The X-ray may be of value in protracted cases. 

Treatment. — If the case is seen early, emptying the stomach by 
induced vomiting or the stomach tube is the first indication. If several 
hours have elapsed and much of the stomach contents have passed into 
the intestine, emptying the colon with an enema will commonly give 
quick relief. Withhold all food for from twelve to twenty-four hours, or 
longer if necessary. In some cases the sipping of hot water will be bene- 
ficial, while in others pellets of ice in the mouth will give some relief. 

Whether or not there existed previous spinal lesions there will al- 
ways be found muscular tension and spinal rigidness during an attack 
of acute gastritis. These should be corrected for immediate rehef, but 
what is of greater importance, if these acute lesions are not corrected the 
patient's recuperative forces are interfered with and recovery is delayed. 
Then, also, these lesions tend to chronicity and predispose to future 
attacks. Treatment should be given daily, or oftener if special indica- 
tions arise. Though the most common area that demands attention 
is from the fourth to tenth dorsals, still the vagi nerves, especially the 
right, should not be neglected. Lesions of the upper three cervicalsare 
the most frequent distm-bances of the vagi. 

Vomiting is a common and distressing symptom. Pathologically, 
it is due to an antiperistatic contraction of the stomach and a spasmodic 
contraction of the diaphragm and the abdominal muscles. It is caused, 
usually, by irritation of the vagus in the stomach, or in the pharynx 
by irritation along the spine (particularly in the cervical and upper dor- 
sal regions), or to the sympathetic nerves or to various parts of the body, 
or by direct influence of the brain. Rehef can usually be given by inhi- 
bition of the vagus in the occipital region or by inhibition at the fourth 
or fifth dorsal vertebra on the right side. In a few instances, placing the 
patient in the knee-chest position and gently raising the abdominal or- 
gans gives relief. If this does not suffice the stomach and colon should 
be emptied, providing the vomiting is protracted. A frequently ef- 
fective measure for nausea and vomiting that can be carried out by 
the attendant, is the application of hot fomentations to the dorsal spine. 



The Practice of Osteopathy 505 

Flatulency may be very distressing. The spinal treatment may 
be sufficient to control this condition, or careful direct pressure for a 
few minutes over the pit of the stomach. Adjustment of the lower ribs, 
especially of the left side, may be effective. Occasionally the gas can 
be passed into the intestines by careful inhibitory treatment in the re- 
gion of the eighth and ninth dorsals. The inhibitory treatment causes 
relaxation of the pyloric orifice; also, inhibition of the left vagus relaxes 
the pylorus. Inhibition at the sixth and seventh dorsals relaxes the 
cardiac orifice, thus favoring the passing of the gas from the stomach 
out through the esophagus. 

In all cases subject to gastritis the dorsal spine should receive con- 
siderable attention in order that recovery may be complete. The hab- 
its of the patient should be thoroughly regulated and over-fatigue guard- 
ed against. And, also of special importance in recurring attacks, is the 
fact that a number of cases present some derangement of the biliary 
tract, or duodenum, or the appendix region. 

Diet. — After twenty-four or forty-eight hours, if the attack has 
been severe, albumin water may be given in small quantities; also whey, 
milk, bouillon, and chicken or lamb broth. If there is no return of gas- 
tric distress, add junket, custard, cornstarch pudding, gelatine, dropped 
eggs, scraped beef, and white meat of chicken; vegetables purees made 
with cream or meat stock are usually well borne at this time. Foods con- 
taining much cellulose, fats and sweets should be withheld until all symp- 
toms have subsided. 

Chronic Gastritis 

It is unnecessary here to repeat the causes of acute gastritis, any 
one of which continued over a long period of time will cause chronic 
catarrh of the stomach, as it is sometimes called. 

Spinal and rib lesions anywhere from the occiput to the coccyx, 
but more particularly from the fourth to the tenth dorsal, wiU predis- 
pose to chronic gastritis, the particular type and degree of local path- 
ology depending upon the exciting factor. 

A commonly found en hloc lesion is a flattening of the normal 
convexity in this region, with more or less immobihzation, shown by at- 
tempting to reestablish the normal convexity through flexion. 

In addition there may be single spinal or rib lesion in the same area, 
or cervical lesions affecting the pneumogastric, which is the secretory 
nerve to the stomach. (See chapter on the "Lesion and Its Applied 
Anatomy. ") 



506 The Practice of Osteopaths 

Pathology. — Chronic gastritis probably never develops as such 
without going through several preliminary stages beginning with .ah- 
mentary hypersecretion, or hypersecretion occurring only during the 
active period of digestion. These are the cases usually classified as hy- 
perchlorhydria. At this time no actual pathology can be demonstrated 
in the glandularis. 

If the condition is not treated intelhgently at this time the next step 
will be periodic attacks of what is known as "hypersecretion periodica 
chronica" followed by "hypersecretion continua chronica." The stom- 
ach contains abnormal amounts of gastric juice even after a night's 
rest. At this stage there is a transition from the functional to the or- 
ganic condition. All stages are characterized by an abundant secretion 
of mucus. 

If allowed to go on there will finally result a destruction of the se- 
creting cells known as Atrophic Gastritis or Achyha Gastrica in which 
the stomach presents a smooth functionless appearance. 

Secondary Chronic Gastritis. — Portal obstruction from any 
cause predisposes to chronic gastritis. The most common of these is 
faihng compensation in heart lesions, which through back pressiu-e causes 
portal stasis; the same thing may follow obstruction in the liver itself. 
Chronic gastritis is also a late accompaniment of the nephritic trinity, 
kidneys, heart and arteries. It maj^ also be associated with diabetes, 
gout, anemia and other constitutional disorders. 

Tuberculosis is commonly ushered in by symptoms of chronic gas- 
tritis. We should be constantly on the alert to avoid the mistake so com- 
monly made of treating the stomach as an entity and overlooking the 
real trouble in some other part of the anatomy. 

It is probably safe to say that there are only two primary diseases of 
the stomach, ulcer and cancer. All others are suspiciously associated 
with diseased processes elsewhere, and when the spinal lesion is given 
its full significance even these will be found to be directly traceable to 
anatomical perversions somewhere within the mechanism of local nu- 
trition. 

Symptoms. — These are governed by the stage of progress in which 
the patient is seen. During the stage of hypersecretion of acid gastric 
juice there will be vague feehngs of distress, fullness and burning in the 
stomach, and "heartburn" during digestion. When the stomach is 
empty all symptoms will subside. Later there will be periods of a few 
days or weeks when there will be more or less continuous distress with 
some vomiting of highly acid gastric juice containing mucus. 



The Practice of Osteopathy 507 

When the condition has progressed to the stage of continuous hyper" 
secretion there will be continuous symptoms as above, but with nausea? 
vomiting becoming more frequent especially late at night or in the morn- 
ing, always accompanied by sticky mucus. 

Appetite is variable, there is often a disagreeable taste in the mouth 
(the "dark brown" taste of the chronic alcohohc). Heart palpitation 
and vertigo and other vagus symptoms are common. 

Diagnosis. — On physical examination the stomach is found dis- 
tended, and in some cases displaced (gastroptosis) . There will be dif- 
fused tenderness on pressure over the whole organ which should help to 
distinguish it from gastric ulcer or cancer in which the tenderness is quite 
locaHzed. 

Chronic gastritis cannot be positively diagnosed without making 
a gastric analysis. Many cases are wrongly diagnosed through neg- 
lect of this very important procedure. 

The cases in which gastric analysis should be made are so well stated 
by Lockwood that we will take the Kberty of quoting them in their en- 
tirety. 

"(1) Gastric analysis should always be made in every case of 
dyspepsia, no matter whether these symptoms be apparently gastric or in- 
testinal, unless passage of the tube is contraindicated. 

"(2) Gastric analysis should be made in every case of chronic 
diarrhea that is not due to evident disease of the colon or rectum. 

" (3) Gastric analysis should always be made in all cases of in- 
testinal toxemia, or recurring headache of toxic origin, and in patients 
who complain of the symptom-complex which is spoken of by the laity 
as 'biliousness'. 

'' (4) Gastric analysis should be made in all cases of anemia and 
general physical wretchedness without known cause and which are re- 
belHous to treatment. " 

The finding of excessive gastric mucus intimately mixed with food 
remnants is the chief differential point in the diagnosis of chronic gastritis. 

Differential Diagnosis. — A complete statement of differential 
diagnosis Ijy Kciup cannot be well improved upon. 

"Chronic Gastritis. — No severe pain, no circumscribed spot, 
painful to pressure; no hematemesis; no cachexia; no marked emacia- 
tion, except in severe cases of long duration; free hydrochloric dimin- 
ished or absent; gastric mucus present; slow course. 



508 The Practice of Osteopathy 

"Ulcer of the Stomach. — Hyperchlohydria present, but not in- 
variably so; severe pain in the epigastrium with intervals free from pain 
vhen stomach is empty; local tenderness which is circumscribed; dorsal 
pain; hematemesis, or occult blood in the stool or gastric contents; mi- 
croscopic pus; no mucus; patient has appearance of suffering; no true 
cachexia. 

"Cancer of the Stomach. — Age usually over forty-five; rapid 
course; free hydrochloric acid usually markedly diminished or absent; 
lactic acid present; pain generally continuous, but not so acute as in ul- 
cer; Boas-Oppler bacillus; cachexia; tumor on physical examination; 
small amount of visible or occult blood; hematemesis much less than 
ulcer; foul odor to vomitus at times present. 

"Achylia Gastrica. — Slow course; scarcely any gastric juice; 
acidity very low or entirely absent; absence of pepsin and rennin; usually 
no mucus or lactic acid. 

"These differential considerations apply to typic cases, and the ob- 
server must be on the qui vive for various gradations and modifications 
of these chnical pictures." 

Prognosis. — The outcome of chronic gastritis depends upon our 
abihty to locate and remove eveiy factor in the etiology, the willingness 
of the patient to cooperate and the patience and resourcefulness of the 
physician. At best the progress is slow and one must expect temporary 
setbacks usually due to failure of the patient to carry out instructions. 

Treatment. — The most successful treatment is prophylactic, but 
until the public has been educated up to this form of economy we must 
begin with conditions as we find them. 

First get the patient's confidence by making an intellegent examina- 
tion, a scientific diagnosis, and a reliable prognosis based upon your 
findings. All lesions, bony, ligamentous, muscular and psychic must be 
intelUgently and carefully removed. 

Specific lesions which would directly or reflexly interfere with the 
nerve and blood to the stomach must be corrected. 

The rigidness commonly found in the vertebrae and ribs of the 
splanchnic area must be overcome first by specific adjustment, and the 
normal flexibility maintained by teaching the patient proper exercises 
for the purpose. This should include deep breathing with the spine 
flexed to the limit, and the ribs fixed, by the patient reaching around as 
far as possible and grasping the ribs as described by Dr. Harry Forbes. 
This will tend to overcome the flat dorsal so characteristic in all gastro- 
intestinal conditions. 



The Practice of Osteopathy 509 

Direct manipulation over the stomach has no particular value and 
may be even harmful. 

Inasmuch as nausea and vomiting and excessive gas formation are 
only the result of hypersecretion we cannot expect to give more than 
temporary rehef except by methods which remove causes. Much com- 
fort may be given by inhibition in the splanchnic area. In severe cases 
it may be necessary at times to wash out the fermenting, irritating mass 
by gastric lavage. Outdoor Ufe, frequent vacations and change of occu- 
pation are often of decided benefit. 

Diet. — Indiscretions of diet must be avoided and this cannot be 
too positively impressed upon the patient. It is always best to make a 
Hst of foods to be taken for breakfast, lunch and dinner and insist that 
no other foods be taken without further instruction. 

Just what these foods shaU be depends upon the gastric secretions 
as shown by gastric analysis. They should always be nutritious and giv- 
en in quantities sufficient to maintain nutrition. 

The stomach should have rest and yet is expected to do its part in 
the process of digestion. All foods must be given in a finely divided form 
and well masticated to spare the stomach the mechanical effort of grinding. 

In hyperacid gastritis all foods of an irritating nature must be posi- 
tively prohibited. The classical breakfast of grapefruit, oatmeal, ham 
and eggs and coffee will not do. Starchy foods must be reduced owing 
to their tendency to ferment in the presence of highly acid juice and the 
delay in the stomach due to the high acidity. 

In subacid gastritis advantage must be taken of the fact that carbo- 
hydrates digest well and proteins do not. 

Diet for Hyperacid Gastritis. — Before breakfast: Wash the 
stomach with warm water and an ounce of Phillips Milk of Magnesia, 
allowing the water to remain in the stomach 20 minutes or a half hour, 
lying down and turning from side to side on the face in order that the 
water and magnesia may be brought in contact with all parts of the stom- 
ach. 

For breakfast: Prunes, allowed to simmer for four hours, without 
boiling, and put through a colander, to remove the skins. Soft cereals, 
such as farina, cream of wheat, or wheatlet, thoroughly cooked, and 
served with middle heavy cream, no sugar. Two eggs, soft boiled, or 
poached. Zweibach, thoroughly masticated, with a hberal quantity of 
butter. Cocoa (Phillips). 

Luncheon: Puree of peas, beans or lentils, made with cream. As- 
paragus, green peas, boiled rice, spinach chopped very fine, creamed car- 



510 The Practice of Osteopathy 

rots, boiled onions, baked potato, well done. Chicken, boiled lamb or 
beef, ground ; oysters in any form but fried ; fresh fish . Desserts : Choice 
of junket, cornstarch, custard, rice pudding, floating island, gelatine 
or tapioca. 

Evening meal: Same as luncheon except substituting eggs for 
meat. 

Cup of hot water before luncheon and dinner. 

If patient requires quick building up give milk between meals and 
at bedtime. 

Gastric Neuroses 

Gastric neuroses include motor, sensory and secretory derange- 
ments. Though the sensory disturbance is often the most marked, still 
motor and secretorj^ symptoms are usually present. In other words 
there is commonly a complex of the different forms. 

Where gastric neuroses can be positively diagnosed, by a process of 
elimination, there is no more plausible explanation than that of the spinal 
lesion. The success of osteopathic physicians in treating so-called " stom- 
ach trouble" proves conclusively the superioritj'^ of the osteopathic 
method. A note of warning should be sounded, however, for as diag- 
nostic methods have become more exact it is found that many cases 
which were formerly diagnosed as neuroses prove to be referred from 
some organic change, such as infected gall bladder, appendix, tube or 
ovary, tonsil, tooth or sinus. It has been proven that many cases of 
sensory and secretory disturbances have entirely cleared up when these 
causes have been removed. Though infection may play an important 
role, still in some instances, especially gall bladder, duodenum and ap- 
pendix, the gastric neurosis may be simply due to a nervous reflex. 

Gastroptosis, atony, and in man}^ cases splanchnoptosis, has been 
found to be the underlying cause of many hitherto vmaccountable gas- 
tro-intestinal symptoms. 

Gastric crisis of locomotor ataxia if not properly diagnosed by the 
finding of the other well known symptoms msLy give us much trouble 
and discouragement. 

Ulcer and cancer have quite characteristic symptoms, yet it is well 
known that they are often treated as neuroses in the early stages, much 
to the detriment of the patient, especially if the' case proves to be cancer. 

In the sensory disturbances, which are probably the most common, 
hyperesthesia and neuralgia are the special features. In the former a 
feehng of weight, fullness and bui-ning are complained of, which are fre- 



The Practice of Osteopathy 511 

quently manifestations of a neurotic temperament. In fact, hysteria 
and neurasthenia are very often basic conditions. The same is true in 
gastrodynia, where the pain starts in the pit of the stomach and extends 
around the lower chest and ribs. There ma}^ be other neurotic symptoms 
such as excessive hunger and a constant desire for food. Menstrual 
irregularities, the menopause, worry, constipation, and anemia are im- 
portant factors. Special care should be taken that there is no organic 
disorder of the gastro-intestinal tract or of the nervous system. 

The motor neuroses comprise a variety of derangements. Excita- 
tion of the motor functions of the stomach, as a direct result of irritated 
nerves or of reflex stimuli, are not uncommon. Owing to this the food 
may not remain in the stomach long enough or the stomach activity may 
be too pronounced. There may be also more or less rapid vomiting of 
the food, without any particular strain. Other motor neuroses may be 
spasms of either the cardiac or pyloric sphincters, and in a few instances 
there may be atony of the stomach walls. Although these conditions 
may be of a neurotic character, still great care should be taken that 
some organic disease is not basic. 

The secretory derangements consist of hyperacidity, supersecre- 
tion, and lessened amount of acid secretion or achyHa gastrica. Many 
of these cases are associated with hysteria and neurasthenia, though in 
achyha gastrica, cancer may be the cause. Hyperacidity may be asso- 
ciated with ulcer. Pelvic diseases, nervous reflexes from the gastro- 
intestinal tract, constipation, and anemia are to be considered as pos- 
sible etiological factors. 

Diagnosis. — These cases require the most painstaldng inquiry into 
the history, the most complete physical examination, and all findings 
carefully checked up by laboratory tests. 

Inquiry will often show that all sjrmptoms subside when on a vacation 
with a change of scene and cKmate. 

Lockwood gives the following rules for arriving at a diagnosis of 
" nervous indigestion. " 

" (1) A diagnosis of nervous indigestion should not be made in the 
presence of more than 30 c. c. of fluid in the fasting stomach, the fluid 
giving a strong reaction for hydrochloric acid. Hypersecretion is gen- 
erally an expression of pyloric stenosis, organic or spasmodic, and this 
is due to an organic cause. 

" (2) A diagnosis of nervous indigestion should not be made in the 
presence of persistent hyperacidity accompanied by epigastric pain. 
Nervous hypcrcliloiiiych'ia may occur, but is not accompanied by either 



512 The Practice of Osteopathy 

pyrosis or pain. The association of either of these latter symptoms 
should suggest an organic origin for the complaint. 

"(3) Achylia gastrica may be of nervous origin, but this is not 
probable when serious motor error is in evidence. Achylia with food- 
stagnation is strongly suggestive of cancer of the stomach. 

"(4) AchyUa gastrica, accompanied by pain or vomiting, indi- 
cates an underlying organic cause. 

" (5) The diagnosis of nervous indigestion should not be made 
when recognizable food remains are repeatedly found in the fasting 
stomach. Under the influence of fear, nervous shock, or vicissitudes of 
temperament the motor functions may be temporarily interfered with, 
but this would not be the case permanentlj". 

" (6) The diagnosis of nervous indigestion should not be made 
when epigastric distress or pain occurs regularly at a definite time after 
eating. The very fact of this disturbance coming on at a definite time 
argues against a neurosis. 

" (7) The diagnosis of nervous indigestion should not be made 
when one symptom alone persists, without other evidences of nervous 
instabiHty. The presence of one definite symptom in itself presupposes 
an organic cause. 

" (8) The physician should be on the qui vive for drug addictions, 
for these habitues can sometimes present a syndrome of s^inptoms that 
will puzzle the most experienced. 

" (9) The diagnosis of nervous indigestion should not be made in 
persons over forty or forty-five, in whom indigestion is a new symp- 
tom. Such patients are usually developing a serious systemic or malig- 
nant disorder. 

"(10) Finally, digestive nervous neuroses and organic disease may 
be concomitant, and the presence of either need not exclude the other." 

Treatment. — First get the patient's confidence b}^ making a most 
complete examination. This desirable beginning is usually hastened 
by the osteopathic physician, when after a few treatments symptoms are 
greatly relieved. Correct all lesions wherever found, particularly those 
anatomically connected with the stomach. When the symptoms are 
sensory rehef can always be given by inhibition over the splanchnic 
area. Occasionally the ensiform process and the lower costal cartilages 
are lesioned. 

Diet. — When hyperchlorhydria is the chief symptom foods must 
be selected which bind acidity or those which lessen its secretion, such 
as milk, eggs, cream cheese, fats such as butter, cream, olive oil, boiled 



The Practice of Osteopathy 513 

or broiled fresh fish, boiled beef or lamb run through a grinder, oysters 
in any form but fried, white meat of chicken, vegetable puree made with 
cream or milk (no meat stock), gelatine, custard, junket or sponge cake. 

Many neurotic patients are under-nourished through fear of food. 
They must be positively assured that if the food is well chosen and care- 
fully masticated there need be no fear of discomfort. Care should be 
taken that the patient is not constipated. 

Some cases can only be reached by a ''rest cure" of four to six weeks, 
which together with the treatment outlined above will prove most satis- 
factory. 

In all cases guard against worry and overfatigue. Build up the gen- 
eral health as rapidly as possible. Outdoor life, sufficient sleep, frequent 
vacations, and change of scene are specially beneficial. 

Gastric and Duodena! Ulcer 

Statistics show that peptic ulcer is far more prevalent than is sup- 
posed by the casual observer. "In the combined statistics of 59,450 
autopsies of various series evidence of healed or unhealed ulcer were 
observed in 4.4 per cent. " (Bassler.) 

The reason for this is that peptic ulcer may present very definite 
symptoms which are readily interpreted or they may be so atypical as to 
make definite diagnosis impossible. Like all gastro-intestinal diseases, 
many of the symptoms are easily confused with so called indigestion or 
" stomach trouble. " 

Etiology. — One characteristic of gastric and duodenal ulcer is that 
it only occurs where the mucous membrane is subject to the influence 
of hydrochloric acid and pepsin; lower end of esophagus, stomach and 
first part of duodenum. 

Similar ulcers are often found in the sigmoid and rectum where the 
feces often become acid due to bacterial action, or on account of slow 
movement, hydrochloric acid and pepsin which may have escaped neu- 
tralization in the duodenum may attack the mucosa. 

For the part played by spinal and rib lesions on the glandular layer 
of the stomach, the reader is referred to a previous discussion of the 
lesion. 

Probable secondary causes of gastric ulcer are: (1) EmboHsm of 
an artery (gastric arteries are terminal). These emboh are supposed 
to be caused by toxic and infectious agencies which enter the circula- 
tion, as sometimes occurs in pyemia and large burns of the skin. 



514 The Practice of Osteopathy 

(2) While hydrochloi-ic acid associated with pepsin seems to be an 
important factor, it is doubtful whether it can attack the mucosa without 
there being a previous abrasion or other injury. It is said that a normal 
secretion of mucus is nature's protection against self digestion. 

The swallowing of substances of a coarse or irritating nature or those 
chemically corrosive or at extremely high temperature may so injure the 
nuicous membrane as to permit an attack by HCl and pepsin. 

Certain occupations seem to predispose to gastric ulcer, such ns 
cobblers, or others who in their work press vaiious objects against the 
stomach. 

Sharp blows oVer the stomach have been followed by acute ulcer. 
A frequently associated condition is gastroptosis, which seems to be 
explained on the basis of narrowing of the blood vessels and their more 
ready occlusion. Probably sagging of the duodenum is an important 
predisposing factor. 

Anemia and chlorosis should not be overlooked as predisposing caus- 
es. And tuberculosis and syphilis are possible associated disorders. 

Of all the theories advanced, the lowering of vitality, due to lesions 
of the splanchnics and vagus nerves remains the most logical. 

Symptoms. — The most characteristic symptom is pain, which in 
a typical case comes on at a regular time after taking food. It may be a 
half hour, an hour or two hours, and in the case of duodenal ulcer may 
be as late as four hours. The distance bej^ond the cardia at which the 
ulcer is located seems to govern the time; also the time at which the se- 
cretion of hydrochloric acid reaches its height, which varies in different 
individuals. 

The pain is due to free acidity (that which is not combined with the 
food) irritating the raw surface of the ulcer. Pain is often increased or 
lessened by posture. If turning on the left side gives relief the ulcer is 
probablj^ at the pylorus ; if worse when standing than reclining the ulcer is 
probably on the greater curvature. 

The pain is usually localized bj^ the patient, and pressure at the 
given spot increases the pain. In many cases there is referred pain in 
the region of the 9th, 10th and 11th ribs on the left side. 

At the height of pain vomiting may occur, due probably to pyloro- 
spasm resulting from high acidity. Vomiting always gives relief. The 
taking of protein food or alkali will usually relieve the pain of ulcer, 
(hunger pain). Ulcer patients are usually well nourished owing to 
the habit of relieving themselves by eating, or they may be thin due to 
their fear of food. 



The Practice of Osteopathy 515 

In acute ulcer frank blood may show in the vomit, and may be the 
first indication of trouble, whereas in the chronic type it may be occult, 
or occult blood may be found in the feces. The hemorrhage of ulcer, 
imHke that of cancer, is not constant. 

Diagnosis. — Diagnosis of duodenal ulcer, as distinguished from gas- 
tric, is made by finding the tender spot to the right and below the pylorus, 
the pain coming on three or four hours after taking food, and the finding 
of blood in the feces (tarry stool) and not in the stomach contents. Re- 
peated examinations may be necessary owing to the fact that hemor- 
rhage is not constant. 

The large percentage of stomach ulcers are near the pylorus, and of 
the duodenal ulcers the ascending portion is the area almost invariabty 
involved. 

Ulcer is differentiated from functional disorders by a history of real 
pain as distinguished from the vague disturbances of sensation often 
called pain by neurotic patients. Also its regular appearance in relation 
to food. The pain of "gastralgia" has no regular habit and is not in- 
fluenced by food. 

Referred pain from cholesystitis, chronic appendicitis, etc. has no 
relation to food and is not relieved by food or alkalies. 

Ulcer is to be distinguished from cancer by the age of the patient 
(in cancer usually over 40) with a previously good gastric history, ex- 
cept in cases where cancer has been grafted on to a chronic ulcer. In 
these cases a careful inquiry will bring out a characteristic ulcer history 
up to a certain time, when all symptoms change; pain becomes constant; 
is not relieved by food or alkaH; vomit becomes dark in color and has a 
characteristic odor, appetite fails, and signs of cachexia set in. 

Gastric ulcer should be suspected in all cases of persistent gastric 
symptoms which are not readily relieved by treatment and regulation 
of diet, and in which there is found high acidity and continuous hyper- 
secretion not accompanied by mucus. 

The X-ray and gastric analysis should never be neglected in 
suspected cases, keeping in mind the possible injuiy from the tube in 
case of recent hemorrhage. 

Treatment. — Osteopathic treatment of gastric ulcer will be almost 
uniformly successful if we will analyze all of the factors entering into the 
problem. 

It is obvious that in order to heal the ulcer we must remove all 
factors which interfere in any way with nutrition. Then give the stom- 
ach as near absolute rest as possible while at the same time building 
up the nutrition by a generous but well chosen diet. 



516 The Practice of Osteopathy 

When acute hemorrhage has recently occurred, complete rest in 
bed with a trained nurse in attendance is the first indication. Complete 
rest of the stomach, all nourishment being given by nutrient enema. 
An ice bag is to be placed over the stomach, and removed every three or 
four hours to allow surface circulation to react. Warm appHcations 
should not be used while there is any marked bleeding. 

During this period no effort on the part of the patient should be 
permitted, and no manipulative treatment which would tend to increase 
blood pressure should be given. 

After all evidence of hemorrhage has ceased for ten days, or at once 
in case of chronic ulcer, we may carefully correct all spinal or rib lesions 
in the splanchnic area especially the 6th dorsal, or cervical lesions af- 
fecting the pneumogastric. Pain and pylorospasm may be I'elieved by 
steady pressure at the 4th and 5th dorsal on the right side. 

After spinal lesions have been corrected without unduly irritating 
the stomach, careful relaxing treatment should be given with the patient 
on the back, keeping in mind that all exertion will tend to irritate the 
ulcer. 

If special care is observed, frequently definite relief may be given by 
placing patient in knee-chest position and gently raising the lower por- 
tion of duodenum where it Hes alongside of ascending 3rd and colon, 
4th lumbar. 

During this period a hot water bag or a thermal pad should be kept 
over the stomach night and day. 

In certain cases of perforation in a few obstinate conditions, and in a 
few where mechanical obstruction is marked, surgery may be indicated. 

The following diet will be found best dimng the first week: 

7 A. M. A half glass of cooked milk, with the leathery substance 
which rises on the top removed, and the yolk of one egg stirred into it 
and sweetened, if desired; taken luke warm or cool, but never ice cold. 
This amount to be increased on the second day to three-fourths of a 
glass, and on the third to a full glass, which is to be continued for a week. 
If the milk produces diarrhea, add two tablespoonfuls of lime water to 
each portion. 

9 A. M. A saucerful of gelatine (Knox's or Crystal Rock) with 
2 tablespoonfuls of cream and a teaspoonful of sugar. 

12 M. A half to full glass of milk prepared as above. 

3 P. M. A saucerful of gelatine, with cream (medium) and sugar 
as at 9 A. M. 

6 P. M. A half to whole glass of milk, as before, with one egg stir- 



I 



The Practice of Osteopathy 517 

red in and sweetened. The egg yolks at 7 A. M. and 6. P. M. are to be 
increased until six are taken daily at the end of the week. 

8 P. M. A half to a full glass of milk. 

The whites of the eggs are to be stirred up in the water in the pro- 
portion of a white to a glass of water, 4 teaspoonfuls of sugar to be added 
to every glass, this to be taken by the patient only when thirsty. 
If the bowels do not move, no laxative can be taken, but an injection of 
warm water or a Httle soap may be employed. If much discomfort is 
produced by the food, a hot compress must be laid over the stomach or 
above the navel. 

During the second week the diet should remain much the same ex- 
cept for the addition of one or two pieces of Zweiback three times a day. 

During the third week, if pain and blood in the feces are lessening, 
we may add soft, well cooked cereal like cream of wheat, cocoa, puree of 
split pea made with cream. 

Fifth week add minced chicken, coddled egg, boiled beef or lamb 
put through a meat grinder, soft vegetables such as chopped spinach,, 
squash and mashed or baked potatoes with liberal quantities of butter. 

Diu-ing and after the sixth week we may add all vegetables which 
can be served in puree form, fresh fish, oysters, apple sauce, inside of a 
baked apple, prune whip, custard junket, corn starch pudding. 

At this time also if all goes well the patient may sit up in bed and 
gradually move about, being careful to avoid all sudden movements 
which would put a strain on the epigastric region. 

If necessary we may also increase our manipulative treatment at this 
time. 

The patient must be warned against the use of any article of diet 
which will be chemically or mechanically irritating to the stomach, for a 
period of months, and an examination of feces should be made from time 
to time to make sure of no return of hemorrhage. 

Dilatation of tlie Stomach 

A dilated stomach is a stretched stomach having increased capacity, 
due to nervo-muscular atony or to pyloric obstruction. Every stomach 
which is not retracted when empty is a dilated stomach. A dilated 
stomach may occur either as an acute or as a chronic condition, but it 
is to be distinguished from temporary distention and a normally large 
stomach. 

Osteopathic Etiology and Pathology. — The nervo-muscular 
atony causing dilatation may be due to obstructive lesions in the stom- 



518 The Practice of Osteopathy 

ach splanchnics, or to a general debility of the spine in the dorsal region 
(usualh^ a kyphosis), or to continued overeating and improper food caus- 
ing a stasis and fermentation. It may also be due to overdrinking and 
various diseases, as phthisis, liver and lung diseases, anemia, chlorosis, 
acute fevers and kidney diseases, causing more or less of a general nervo- 
muscular atony. Dilatation may result from a mechanical obstruction, 
or narrowing of the pylorus or the duodenum, by a cicatricial contraction 
of an ulcer; by hypertrophic thickening due to various diseases, by ad- 
hesions and tumors. Occasional^ the pyloric obstruction is congenital. 
A floating kidney may fall upon the horizontal portion of the duodenum 
and thus mechanically obstruct the passage of food from the stomach, 
which consequently dilates. Tight lacing might prevent the liver, when 
congested, from passing in front of the kidney, thus luxating the kidney. 
Dilatation of the stomach occurs at all ages, although most frequently 
in middle aged persons. 

Pathologically, the nuiscular coat is thinner and paler than nor- 
mal, with more or less atrophy of the glandular tissues and an increase 
in capacity of the stomach. When obstruction exists at the pylorus, 
hypertrophy of the muscular coat may occur. 

Symptoms. — The symptoms are those of the disease causing the 
dilatation plus those of persistent chronic catarrh. The patient com- 
plains of a sense of fullness in the epigastric region and there is flatu- 
lency, eructations and vomiting. The cavitj^ of the stomach being much 
enlarged, great quantities which are usually considerably decomposed 
are vomited each day or two. There is often lessened acidity of the 
vomited mass, though in some cases it is increased. Passage of the food 
from the stomach to the intestine is delayed and the bowels are consti- 
pated, the fecal matter being dry and hard. The urine may be scanty 
and the skin dry. Anemia, debihty and emaciation are always present 
to a greater or less extent, and on account of the absorption of poisonous 
matter drowsiness maj^ occur. 

Physical Signs. — Inspection. — In some cases the outline of the 
distended stomach can be plainly seen. There is prominence of the epi- 
gastric region, the tumefaction being at the pyloric end of the stomach. 
Palpation. — The resistance upon manipulation of a dilated stomach is 
like that of an air cushion. If the patient is made to drink a half tumbler 
of water, bimanual palpation will cause a splashing sound to be heard 
along the circumference of the stomach at its lowest point; and by mov- 
ing the water about by changing the position of the patient, the outline 
of the stomach can be made. If the sound is not heard at the first manip- 



The Practice of Osteopathy 519 

ulation, it must not be concluded that the stomach is normal for the 
stomach may be so dilated and flabby that it falls behind the abdominal 
wall like an apron. Percussion. — The note is tympanitic over the 
greater part of the stomach until the lower curvature is reached when 
the sound is dull (due to the Kquid contents of the stomach) , followed by 
a tympanic sound again when the intestines are reached. When per- 
cussion is made the patient should always be in a standing position if 
possible. 

When there is pyloric obstruction a tumor usually presents itself, 
and vomiting is more severe and peristalsis more active than when the 
dilatation is due to atony of the walls of the stomach from an obstructed 
innervation. 

Diagnosis. — This is usually easy if due care is taken in making the 
examination. Goetz has shown by the use of his spinegraphometer 
that in cases of visceral prolapse the spine is commonly posterior in 
the dorso-lumbar region. The X-ray is of value in determining the 
size and function of the organ. 

Prognosis. — In a case of nervo-muscular atony the prognosis is 
favorable. If due to a mahgnant disease recovery is usually impos- 
sible. In hypertrophy of the pylorus or the duodenum, recovery is 
probable by means of surgical interference. 

Treatment. — When the dilatation is due to atony of the mus- 
cular walls of the stomach from obstructed innervation at the spinal 
column, treatment is usually successful. Attention should be given 
to the condition of the spinal column in the splanchnic region (fourth 
dorsal to twelfth dorsal), the spine being usually posterior. A thorough 
and persistent course of treatment must be given, not only to restore the 
normal activity of the nerves to the muscular coat and glands of the 
stomach, but to build up and restore strength in the weakened spinal 
column. Lesions in the spinal column, even higher than the fourth 
dorsal, may affect the innervation of the stomach. There are cases 
where lesions have been found at the fifth, sixth and seventh cervicals 
that interfere considerably with the action of the stomach, causing nau- 
sea, flatulency, eructations, and even vomiting. Such an affection may 
l)e through the fibers of the splanchnic nerves or through fibers of the 
vagi nerves. 

The vagi nerves have an important bearing upon gasti'ic dilatation 
as paralysis of the gastric branches of the vagi arrests the peristalsis of 
the stomach and thus tends to favor retention of food within its cavity. 
The stomach in such cases becomes enlarged, mainly by the weight of 



520 The Practice of Osteopathy 

the food and the presence of gases due to decomposition of the retained 
food. Thus lesions may be found higher than the lower cervicals and 
cause obstruction and paralysis of the fibers of the vagi to the stomach. 

Direct stimulation over the stomach in the form of thorough manipu- 
lation of the stomach walls causes contraction of the muscular fibers of 
the stomach, mainly the circular fibers. This treatment, with addi- 
tional treatment of the splanchnic and the vagi nerves, will tend to build 
up the weakened plexuses of the stomach. Much time can be saved 
by putting the patient to bed and treating him every day for several 
weeks. When the stomach is dilated or dilated and prolapsed, to any 
extent, it usually requires three to five months treatment at least; this 
time can be shortened one-half by keeping the patient in bed, treating 
the spine three times a week, and the abdomen everj^ day. Light food 
at frequent intervals, upper thoracic breathing, and frequent drawing 
up and in of the abdomen should be required. The patient may also 
manipulate his own abdomen twice a day to advantage; teach him to 
manipulate, draw and pull it upward. There is no danger of too fre- 
quent treatment as long as there is no bruising of the parts; this, how- 
ever, does not apply to the spine. It is not an uncommon thing to cor- 
rect a dilated stomach or a dilated and prolapsed stomach that is an 
inch and a half or two inches below the umbilicus. Care must be taken 
in all cases that other viscera are not prolapsed. It is a common ex- 
perience to find enteroptosis, which can usually be readily functionally 
corrected, with the stomach ptosis. But where the kidney, or possibly 
both, is much prolapsed only fair results can be secured until the kid- 
ney is replaced and kept there, and if necessary by surgical means. Also, 
note whether the liver is enlarged. (See special article on Prolapsed 
Organs) . 

When the disease is due to cancer and various growths of the py- 
lorus or the duodenum, nothing can be done but palliate. Such cases 
require surgical attention. In all cases it is necessary that care and 
preoccupation of the patient should be removed. Baths, changes of air, 
a carefully regulated diet and caution in the use of liciuids will be of great 
aid to the general health of the patient, and thus the weakened nervous 
system will be indirectly but greatly benefited. Too great care cannot 
be taken of the patient, as there is created in the organism a special 
aptitude for the tissues to become inflamed and thus weaknesses at 
various parts of the body may occur. Phthisis, typhoid fever and 
various diseases are apt to follow dilatation of the stomach, as the nu- 
tritive and resistive process of the body are impaired. 



The Practice of Osteopathy 521 

The meals should be taken regularly and with great care, the pa- 
tient not eating too quickly nor too much. SoHds should be used but 
little; the artificially digested foods, such as peptonized milk and beef 
peptonoids, probably being the best. Beef juice and scraped beef are 
excellent foods, as they are easily digested. Fatty and starchy foods 
should be avoided. 

Washing out the stomach is useful, but it should not be indiscrim- 
inately employed. Lavage will not be necessary in all cases of mechan- 
ical obstruction. It relieves the distention, by removing the weight 
and the fermenting and decomposing material. 

In acute dilatation, which may be due to prolonged diseases, gen- 
eral anesthesia, injuries of the spine, and to narrowing of the duodenum, 
vomiting, pain and collapse occur. Empty the stomach, and place pa- 
tient in knee-chest position. Reach beneath the duodenum and raise 
this part of bowel. Start well down, as low as third or fourth hmibar. 
If this does not give quick relief stand patient on his head. 

Gastroptosis and Enteroptosis^ 

(Glenard's Disease) 

Definition.^ — A displacement of the stomach and intestines. 

Osteopathic Etiology and Pathology. — A weakened, debihtated 
spine is the common cause. A slight posterior curvature is a frequent 
occurrence. A debihtated spine impairs the innervation to the abdom- 
inal viscera and to the muscles of the abdomen. Many cases are of 
congenital origin due to lack of complete development and weakness of 
the supporting tissues. Other causes are muscular strain, repeated preg- 
nancies, tight lacing and malnutrition. A downward displacement of 
the floating ribs, and a consequent prolapse of, and atonj^ of the dia- 
phragm, is an important cause. 

Prolapses of the stomach and intestines are of frequent occurrence 
in both sexes, and very common in women. It is a condition often- 
times overlooked, and when recognized, httle has been done in the way 
of a cure. It is the cause of much disturbance, not only to the stomach 
and intestines, but to the various abdominal viscera and to the pelvic 
organs, and it is the cause of a large percentage of prolapses of the utei'us, 
(excluding lacerations from childbirth) for not only is the great suspensory 
ligament of the uterus (the peritoneum) prolapsed as a consequence, but 
all of the abdominal viscera and the parietes of the abdomen are also 
prolapsed and crowded down into the pelvis. The small or large intes- 

1. See special article, Prolapsed Organs, Part I. 



522 The Practice of Osteopathy 

tine or the stomach may be prolapsed singly. Tliis is frequently the 
case with the transverse portion of the colon, which may be elongated 
and tortuous and prolapsed nearly to the S5anph3'sis pubis. Prolapse 
of the liver, spleen and kidnej's may occur singly or with a general dis- 
placement of all the organs. 

Symptoms. — The abdominal walls are weak, oftentimes flabby. 
The viscera of the abdomen do not have normal resistance upon manipu- 
lation. The spinal column presents lesions. There is dypspesia, flatu- 
lency, constipation, abdominal pains and various neurasthenic symp- 
toms. 

Diagnosis. — Is readily made by the lack of tone to the abdominal 
walls and viscera and the general debility of the patient. Inflation of the 
stomach with air will determine between gastroptosis and dilatation. 
The X-ray is of special value in determining position, function, spasms, 
kinks, etc. of the digestive tube. There are innumerable gradations 
and phases of this condition. 

Treatment. — To remove the cause is of primary importance. This 
is to be followed by treatment of the spinal column, correcting its various 
derangements and improving the innervation to the atonied viscera and 
abdominal parietes. Direct treatment over the abdomen helps to give 
tone to both the viscera and abdominal muscles. In many cases the 
treatment will have to be a prolonged one in order that the tissues may 
regain their normal condition. Usually a treatment from two months 
to a year, or possibly more, is required. Exercises and manipulations 
that tone the tissues, correct the posture, and raise the chest, diaphragm, 
abdominal and pelvic viscera, and release spasms, kinks, and adhesions, 
are indicated. The diet of the patient should be nutritious, and sufiicient 
in emaciated cases to increase his weight if possible. A supporting 
bandage will often give some relief. A few cases will require surgery. 

Particular attention should be given to the colon, duodenum and 
diaphragm. 

Relative to the treatment of gastroptosis and enteroptosis, W. E. 
Harris writes as follows: "I first set to work trying to correct the spinal 
irregularities; coupled with this I give deep and careful manipulation of 
the gastric and intestinal walls — treating my patient two or more times 
per week for a period of one to three years. A lesser period is not long 
enough to bring the desired result in such cases. I also instruct the pa- 
tient to knead his own bowels, which I prescribe as a necessary proceed- 
ing, and to be performed twice daily on retiring and before rising. Of 
equal importance with the osteopathic treatment, come local, spe- 



The Practice of Osteopathy 523 

cific abdominal exercises. These are to be of the resistive type, and 
must also be taken for the general musculatm-e. I have my patient 
retract the abdominal walls and voluntarily draw the abdominal con- 
tents towards the diaphragm, in regular series. These exercises must be 
faithfully performed and continued after the treatment has ceased in 
order to be of real value. I do not find our treatment, without the hearty 
cooperation of the patient in doing his exercises conscientiously, to be 
sufficient in itself. Have the patient avoid overloading the digestive 
tract. Use concentrated foods, in small quantities, i. e., only sufficient 
to sustain strength, twice daily and without taking fluids at meal times. 
Of course water, in small quantities and at frequent intervals, may be 
taken between meals. To summarize — First, corrective treatment. 
Second, resistive exercises. Third, attention to diet." (See Dilatation 
of the Stomach.) 

DISEASES OF THE INTESTINES* 
Acute Diarrhea 

Definition. — A diffuse inflammation involving the entire intestinal 
tract to a greater or less degree. Usually the seat of disease is found in 
the small intestine and the upper part of the large bowel. 

Osteopathic Etiology and Pathology. — Acute diarrhea may be 
caused by overeating, drinking impure water, unripe fruits, and poisons 
produced in decomposed and fermented milk and other articles of food. 
This sometimes takes place in perfectly harmless substances in an in- 
explicable manner. Milk and ice cream may produce intestinal ca- 
tarrh. Dr. Still often referred to the harm resulting from iced drinks. 
Changes in the weather, tending to weaken the system, often cause diar- 
rhea; hot weather favors this, although a chilhng of the system by a 
sudden fall in the temperature may produce the disorder. Dr. Still 
was of the opinion that sitting on the cold ground (a common habit of 
children) is a frequent source of intestinal derangements. Changes in 
the quantity and quality of the secretions also induce the disorder; thus 
the bile, if in too great a quantity, increases the peristalsis to such a 
degree that diarrhea is produced; if diminished, it favors the fermenta- 
tion and decomposition of the food. Pancreatic diseases may be a cause 
of diarrhea. Infectious diseases, through their specific poisons, such as 

*The student will receive many helpful suggestions by reading Macleod, Physi- 
ology and Biochemistry in Modern Medicine; Cannon, The Mechanical Factors of 
Digestion; Carlson, The Control of Hunger in Health and Disease; Gaskell, The 
Involuntary Nervous System; Pottenger, Symptoms of Nervous Disease. 



524 The Practice of Osteopathy 

cholera, dysentery and typhoid fever; inflammation, extending into the 
bowels from adjacent parts; inflammation caused by peritonitis and in- 
testinal obstructions, as invagination and hernia; hyperemia, secondarj^ 
to diseases of the liver, heart and lungs; cachectic states met with in 
Addison's disease; the last stages of Bright 's disease; cancer and marked 
anemia are all among the causes of diarrhea. 

As in constipation, diarrhea is oftentimes simply a sjTuptom of var- 
ious disorders; still, it may be the only symptom manifested. Lesions 
are found in various regions of the body, but chiefly in the lower dorsal 
and lumbar vertebrae and the lower ribs at either side. Also lesions may 
be found to the vagi, thus increasing the peristalsis or affecting the blood 
suppl}^ of the intestines. The lesions to the splanchnics may involve the 
motor, vasomotor or secretory fibers to the intestines. Oftentimes the 
innervation to the liver is disturbed, affecting the secretion of the bile. 
The left side of the spinal column is involved more often that the right 
side, by vertebral, rib and muscular lesions. 

Nervous Diarrhea frequently follows fright and other causes of 
nervous excitement, and is often found in hysterical women. There is 
simply an increase in the peristalsis and secretion of the bowel, due to a 
vasomotor paresis of the intestinal vessels, producing an outflow of the 
serum. 

The intestinal condition is one of hyperemia. The secretory glands 
are frequently inflamed. In decided cases the mucous membrane may 
be red and injected, but more often it is pale and covered with a layer 
of mucus. Sometimes the solitary follicles are considerably enlarged. 
These enlargements may become filled with pus, forming abscesses which 
rupture, leaving an ulcer. Peyer's patches may also be involved. 

Symptoms. — The diarrhea is the important, and often the only, 
symptom of enteritis; the stools are frequent, varying from two or three 
to fifteen or more a day; they are thin and watery, varying in color ac- 
cording to the amount of bile they contain. They are usually of a yel- 
lowish or greenish color. They contain undigested food, mucus, colum- 
nar epithelium and mucous cells, micro-organisms and triple phosphate. 
The reaction of the discharge is either acid or neutral. There are coUcky 
pains in the abdomen, rumbling noises or borborygmi, intense thirst, 
dry and coated tongue, with loss of appetite, and, rarely, a fever. When 
fever is pronounced care should be taken that some infectious disease is 
not the cause. Chronic catarrhal diarrhea may follow the acute 
form. If the stools contain much undigested food the inflammation is 
in the upper bowel; if thin, watery and containing mucus, the lower 



The Peactice of Osteopathy 525 

bowel is involved. In prolonged cases the general health is affected. 
Definite tender areas along the spine and deep muscular contractions are 
invariably important etiologic and diagnostic clues. 

Diagnosis. — This is ordinarily made easy by giving attention to 
the above, symptoms. In distinguishing as to whether the large or small 
intestines are involved the following is important: In catarrh of the 
small intestines, diarrhea is not so well marked; there is much undi- 
gested food, but very little mucus; and there is usually pain of a colicky 
nature in the middle or inferior part of the abdomen. When the large 
intestine is involved there may be no pain; when present, it is intense 
and usually in the upper and lateral parts of the abdomen; there are 
borborygmi and thin, soupy stools, mixed with much mucus. If the 
lower portion of the bowel is involved there may be marked tenesmus, 
with marked contraction of the muscles over the sacral foramina. 

Duodenitis is often associated with acute gastritis. Placing the 
patient in the knee-chest position one may be able to palpate the duo- 
denum. If the inflammation involves the bile duct, there is jaundice; 
in these cases the urine may be bile-stained. 

Prognosis. — Commonly favorable if early and prompt treatment 
is employed; though it should be remembered that some infections, or 
constitutional disease, or intestinal ulcer may be an underlying cause. 

Treatment. — Many cases of acute diarrhea will recover by re- 
stricting the diet, with rest. Where improper food and water are the 
causes, an entire change of diet should be considered. Withdrawal of 
all food and the substitution of boiled milk will be of great aid. The 
bowels should never be confined if there is reason to suspect that all ir- 
ritating matters have not been removed; and when fermentation and ir- 
ritation exist in the lower bowel, an enema will often be beneficial. The 
spinal column should be examined, especially on the left side, from the 
fifth dorsal down to the cocyx. The vertebrae may become displaced 
and cause diarrhea, by derangement of the vasomotor nerves. 

Either an increased blood supply through the intestines, or an affec- 
tion of the motor nerves will produce an increased peristalsis. An ac- 
tive condition of Meissner's plexuses may be produced sympathetically, 
resulting in increased secretion of intestinal juice and thus in diarrhea. 
The ribs may become displaced and be a source of irritation to the nerves 
of the intestines. The muscles of the spine are apt to become contracted 
by colds, injuries, strains, etc., and stimulate or inhibit the action of 
certain centers in the cord and produce disordered intestines. Conversely 
the muscles of the back may be thrown into a contracted condition by 



526 The Practice of Osteopathy 

irritating substances in the bowels acting as a stimulus to the centers in 
the cord, and thus reflexly to the muscles. Trouble may arise in the colon 
and rectum bj' lumbar lesions, the shpping of an innominate, a dislocated 
coccyx, or contracted muscles over the sacrum. In a word, thorough 
inhibition, relaxing contracted muscles and correcting abnormal verte- 
brae and ribs are the osteopathic essentials of treatment for diarrhea. 
Inhibition of the lower dorsal and lumbar is very effective; it dilates the 
mesenteric vessels by way of vasomotor fibers, and thus controls secre- 
tions and lessens peristalsis. This has been clearly proven in the osteo- 
pathic experimental work of Burns and Pearce. 

Hot fomentations over the dorsal and lumbar spine will frequently'', 
through the nervous reciprocal relationship, be of decided value. 

Direct treatment over the mesenteric circulation, i. e., through 
the abdomen anteriorly, will be helpful in some cases. It relaxes tissues, 
removes irritations and frees the circulation generally about the mesen- 
teric vessels and intestines. When giving this treatment one should be 
certain of the underlying pathology. The hver should be kept active. 
Treatment of the vagus nei'ves is important, as they help to control the 
blood supply and the motor nerve force through the intestines. Daily 
hot baths and increased activity of the skin and kidneys are beneficial. 

Chronic Diarrhea, and Mucous Colitis 

Definition. — A chronic inflammation of the mucous membrane of 
more or less of the large intestines. There may be ulceration. 

Osteopathic Etiology and Pathology. — Chronic diarrhea may 
be the result of repeated attacks of the acute form or may be caused by 
cancer, tuberculosis, Bright's disease, typhus fever, disease of the hver, 
organic disease of the heart and lungs, obstructions to portal circulation 
or impactions of any nature that occasion passive congestion. Fre- 
quently cases of long standing are due to chronic lesions of the lower 
ribs or lower dorsal or lumbar vertebrae. The lesions of the lower ribs 
usually consist of downward displacement of the ribs, affecting the in- 
nervation to the intestines directly, or possibly dragging the diaphragm 
downward to such an extent as to interfere with the blood and lymph 
vessels as they pass through it, thus causing congestion of the intestines 
by obstruction to the lumen of the vessels. 

In many cases the pathological changes are simply those of the 
acute form. In more pronounced cases the mucous membrane becomes 
a brownish red, Hvid gray or slate color; this discoloration being due to 
hyperemia and blood extravasation. The mucous coat is also swollen. 



The Practice of Osteopathy 527 

and thickened. Atrophy of the mucous membrane, and in some cases 
of all the coats, with destruction of the glands, may be a result of the 
chronic form. Ulcerative changes occur chiefij^ in the lower part of the 
ileum and colon; these msiy be follicular or there may be large ulcers and 
considerable areas of ulceration. 

Symptoms. — Constipation and diarrhea frequently alternate; 
the stools are thin, mixed with a large amount of slinw mucus ; the small 
intestine is most frequently involved, and the patient complains of pain 
in the umbilical region; there is distention of the bowels with gas; the 
health gradually declines; there is great pallor, and the patient becomes 
emaciated, gloomy and irritable. 

Mucous Colitis is a chronic form of colitis, characterized by par- 
oxj^sms of severe pain and the discharge of large masses of mucus, forming 
gray translucent casts, which are not fibrinous but mucoid in character. 
This disease occurs usually in women of nervous type, but is occasionally 
seen in men and children. When there is no underlying organic disease, 
it is probably largely a secretion neurosis. Mental emotions and worry, 
sometimes errors in diet, or dyspepsia bring on the attack. Over-fatigue 
is often an exciting factor. The nurtition is generally well maintained, 
but in other cases there may be a gradual emaciation and ultimate death. 
This is undoubtedly one of the most persistent and troublesome diseases 
that one will meet; still the osteopath can do much for these cases and not 
infrequently bring about a cure. But the treatment must be consistent 
and persistent. 

Mucous coHtis is not hard to diagnose, although many cases are 
treated for simple indigestion. It is needless to say that a correct diag- 
nosis is paramount. In these cases there is almost invariably some vis- 
ceral prolapse, which undoubtedly is the underlying cause, by favoring 
venous congestion of the bowels. The liver is usually congested; this 
alone may cause the venous stagnation, but more often it is simply due 
to the common cause. Back of the visceral prolapse and congestion will 
almost invariably be found a posterior dorso-lumbar curvature; still 
there may be a scoliosis or single lesions only, and a downward displace- 
ment and constriction of the floating ribs. 

The treatment requires most persistent and careful work for at 
least three months, and probably six to nine months. Correction of the 
spine and floating ribs should be of first consideration; then intelligent 
treatment over the abdomen, by raising and toning the bowels, not only 
the bowels as a whole, but especially in the ilco-cecal, hepatic flexure, 
transverse colon, splenic flexure, sigmoid flexure, and rectal regions. 



528 The Practice of Osteopathy 

The direct treatment should be cautiously given when there are indica- 
tions of ulceration. 

Have the patient help himself b}^ manipulating his bowels night 
and morning, drawing the abdomen up and in, and by thoracic breathing. 
Prescribe plenty of drinking water and reduce starchy and saccharine 
food to a minimum. Again emphasis is placed upon the necessity of per- 
sistent treatment, two and three times per week, for several months. 
The mucus is hard to remove. It is tenacious and frequently causes 
cohcky pains. 

To the student Von Noorden's^ monograph on this subject is espec- 
ially instructive. He notes that almost without exception the patients 
suffer for some weeks or months prior to the development of colica mucosa 
from obstinate constipation. For acute attacks, among other things, he 
advises rest in bed, hot apphcations, and high water injections. He 
beheves in massage of the large intestine (particularly of the sigmoid 
flexure), in cases of atonic constipation and also in spastic constipation, 
provided the patient has a diet that leaves a large residue. "A coarse, 
laxative diet of Graham bread, leguminous plants, including the husks, 
vegetables containing much cellulose; fruit with small seeds and thick 
skins, Uke currants, gooseberries, grapes; besides, large quantities of fat, 
particularly butter and bacon. " 

Diagnosis. — Diagnosis is always easy. The presence of blood, 
pus, or fragments of tissue in the stool point to ulceration. Ulcers in 
the rectum, and as high as the sigmoid flexure, will be recognized by ex- 
amination with the speculum. 

Prognosis. — Osteopathy has undoubtedly changed the prognosis 
of other treatment. Many cases can be cured and most other cases 
greatly benefited. The deep seated ulcerations may cause circumscribed 
peritonitis, or even abscess, and the prognosis becomes grave as these 
complications arise. 

Treatment. — As diarrhea may be caused by lesions anywhere from 
the sixth dorsal to the coccyx, a most thorough examination is necessary. 
On the one hand, diarrhea may be due to a marked lateral or posterior 
spinal curvature, which is plainly seen upon inspection, but on the other 
hand, it may be due to a sHght twist or deviation from normal of a ver- 
tebra which would require considerable osteopathic ability to exactly 
locate. Diarrhea may result from subluxation in the lower costal region, 
one or more of the three lower ribs on either side being involved. Record 
of one case, in particular, of chronic diarrhea is of interest as it was due 
1. Von Noorden, Colitis, 1904. 



The Practice of Osteopathy 529 

to a rib dislocation. It was the case of a man fifty years of age, who had 
suffered from chronic diarrhea, several stools a day, for over thirty years. 
He was completely cured in one treatment by correcting the dislocation 
of the vertebral end of the tenth rib on the left side. This case is cited 
to impress upon the student the necessity of precise diagnosis and treat- 
ment. Rarely will diseases be cured by a single treatment, but when 
such happens it exemphfies the potency of the osteopathic lesion. Treat- 
ment on the left side is usually more effective in diarrhea than treat- 
ment on the right side. When diarrhea is a symptom of some constitu- 
tional disturbance, correction of dorsal, lumbar and rib lesions, with 
thorough inhibition, careful dieting and rest, will commonly suffice pro- 
vided the primary disease is intelligently looked after. 

Chronic lesions of the vagi nerves may exist and produce chronic 
diarrhea in the same manner as in acute diarrhea. Rest and a hquid diet, 
preferably boiled milk and albumin water, will be a helpful treatment; 
the diet requirement is to have a minimum amount of waste, so that the 
residue will cause the least possible irritation. Beef peptonoids with 
the milk will be a nutritious addition to the diet, and change of air and 
surroundings may be an aid to a more speedy cure. The skin and kid- 
neys should be kept in a healthy condition and, if necessary, the bowels 
thoroughly emptied by injections. 

Diarrhea of Children 

Three forms of diarrhea are recognized in children : Acute dyspep- 
tic diarrhea, cholera infantum, acute enterocoHtis. 

Acute Dyspeptic Diarrhea 

This disease is most frequently due to errors in diet; the mother's 
milk may be d,ltered in quantity or quahty from taking improper food; 
the child may be over-nursed, or the foods given in place of the mother's 
milk are at fault. Too often a filthy bottle is the cause. The predis- 
posing causes are dentition and extreme heat; and these, combined with 
constitutional Aveakness, bad hygiene and a weak spine, diminish the re- 
sisting power of the infant. Hence, in artificially fed children of the 
poorer classes, this disease is very prevalent. 

Pathologically, there is catarrhal swelling of the mucosa of both 
the small and large intestines. The amount of mucus is increased, and 
there is more or less involvement of all the lymphoid tissue. The sub- 
mucous membrane is often infiltrated. If there is much inflammation 
ulcers mav occur. 



530 The Practice of Osteopathy 

Symptoms. — The child may seem to be in its usual health, with 
slight restlessness at night and an increased number of stools. This 
restlessness may be due to nausea and cohcky pain. The stools are 
copious and offensive, containing undigested food and curds. In chil- 
dren over two years old these attacks maj^ follow the eating of unripe 
food or drinking tainted milk. In other cases the onset may be sudden 
with vomiting, purging, and griping pains. The fever may rise rapidly 
to 103 or 104 degrees or more, sometimes followed by convulsions. The 
stools become more numerous — there may be twenty in the twenty-four 
hours — gray or green in color, and sometimes containing much mucus, 
rarely blood. 

Diagnosis. — The sudden onset and the character of the stools, which 
never have a watery, serous character, distinguish this from cholera in- 
fantum. And the small amount of mucus which the stools contain 
distinguishes them from those of ileo-colitis. This form often precedes 
the onset of specific fevers. 

Prognosis. — Among the better classes this is generally favorable, 
but among the weak, half-starved children of the poor it is often unfav- 
orable, especiall}' in hot weather. 

Treatment. — The child should be clad warmly, kept absolutely 
clean and given a change of diet and air if possible, with frequent baths. 
Sterihzed milk should be given at regular intervals ; or if the diarrhea con- 
tinues, beef juice and egg albumin instead. The bowels should be thor- 
oughly cleansed by injections. The spine should be thoroughly treated 
through the lower dorsal and lumbar regions, and if the abdomen is not 
sensitive, a Kght treatment to the bowels directly will aid recovery. Fre- 
quently it will be found that the muscles of the neck and upper dorsals 
are considerably contracted, especially where the child has fever and is 
very restless. 

For acute intestinal indigestion Ruhrah gives the following di- 
etetic treatment: "Withhold all food for the first twenty-four hours, 
except a httle albumin-water. This is best given in small doses at not 
too great intervals. Plain boiled water may be used instead. Very 
weak tea to which a httle red wine has been added may be given if the 
child is weak. On the second day the albumin or barley-water may be 
given with the addition of weak strained broth, and on the third day 
malted milk may be added to the list. After four or five days cow's milk 
diluted and boiled or peptonized may be tried. It is best mixed with a 
farinaceous gruel or with malted milk to start with. It may be given 



The Practice of Osteopathy 531 

every other feeding for a day or two if it agrees, and the former feeding 
gradually resumed. 

"In nursing infants withhold the breast twenty-four hours and 
feed as above. After that the breast may be given once for a few min- 
utes and the feeding pieced out with albumin- or barley-water. If it 
agrees the breast maj^ be given for three or four feedings, every other 
feeding followed by albmnin- or barley-water. On the following day the 
breast may be given at each feeding. The time of nursing should be 
increased gradually until the child is back on its old schedule." 

Cholera Infantum 

Definition. — An acute, catarrhal inflammation of the mucous mem- 
brane of the stomach and intestines, with some disturbance of the sym- 
pathetic ganglia. This is a disease of childhood during the first dentition. 

Etiology and Pathology. — Probably due to the poisonous products 
of decomposing and fermenting foods acting upon the system. The pre- 
disposing causes are hot weather, dentition, bad hygiene, the previous 
presence of some sHght dyspeptic derangement, dyspeptic diarrhea, and 
enterocolitis. 

The pathological changes are similar to the morbid anatomy of 
catarrhal gastritis and enteritis. The serous discharges and rapid col- 
lapse are due to the intense irritation of the sympathetic system. The 
kidneys and liver may become involved, and bronchopneumonia is a 
possible compHcation. 

Symptoms- — The disease is of sudden onset, setting in with severe 
vomiting, which is increased by giving food or drink. The stools are 
copious and frequent, at first containing some offensive fecal matter, and 
later becoming watery, and odorless. There is decided fever, reaching 
as high as 105 degrees. The pulse is rapid and feeble, ranging from 130 
to 160. Prostration, pinched features, hollow eyes, depressed fonta- 
nelles and loss of weight are characteristic symptoms. The tongue is 
coated at first, but soon becomes dry and red, and thirst is intense. Even 
at this time a reaction may set in, but more commonly death results 
with sj^mptoms of collapse and high temperature. In other cases there 
are restlessness, convulsions and coma. As there is no cerebral lesion, 
this condition is prol^ably due to toxic agents absorbed from the intes- 
tines. 

Diagnosis. — This is not difficult, as the toxic symptoms, the se- 
vere vomit ing, the profuse watery discharge, rapid emaciation and pros- 
tration, and the hyperpyrexia arc significant. 



532 The Practice of Osteopathy 

Prognosis. — Grave, even with the most favorable surroundings, 
although in numerous instances osteopaths have successfully treated this 
disorder. Much depends upon the promptness of treatment. 

Treatment. — A change of air, complete rest, removal of all foods 
for a short time, and absolute cleanliness are of great importance. 
Thorough treatment should be given along the entire spine, particularly 
to the splanchnics of the stomach and the intestines, and to the vagi 
nerves in the cervical region. Frequent bathing with cool water, or 
better still, wrapping the child in cold, wet sheets, will reduce the hyper- 
P3rrexia. 

Thorough cleansing of the stomach and intestines with warm water 
occasionally gives excellent results. In collapse the use of a hot bath 
is indicated, followed by wrapping the child warmly in blankets and plac- 
ing him in a horizontal position. The food of the cliild should consist of 
peptonized milk, raw beef juice, diluted egg albumin, barley water and 
chicken broth. Nourishment should be given gradual^, and only after 
the intense symptoms have subsided. 

Acute Enterocolitis 

In enterocolitis the ileum and colon are chiefly affected, especially 
the lymphatic glands or lymph folhcles. 

Osteopathic Etiology and Pathology. — Warm weather, the 
artificial feeding of children, dentition and bad hygiene are predisposing 
causes. The disease usually occurs between the ages of six and eighteen 
months, but it is not infrequent in the tliird or fourth year. This dis- 
ease is not confined to the warm weather, but may set in at any season of 
the year. Previous hght attacks of diarrhea are often a predisposing fac- 
tor. Lesions in the spine occur from the eleventh dorsal to the fourth 
lumbar. 

The mucous membrane is congested and swollen, and the sohtary 
follicles and Peyer's patches are swollen and often ulcerated. The 
changes may end here or the ulcers enlarge and extend into the muscular 
coat with the separation of a slough. There may be infiltration and 
thicking into the submucous and muscular coats, followed by induration 
of the tissue, producing abnormal rigidity. 

Symptoms. — The disease may be a sequel of dyspeptic diarrhea 
or cholera infantum. The temperature increases and the stools change 
in character, being at first yellow, and later green. They contain traces 
of blood and mucus. Vomiting may be present, but is not a constant 
symptom. The abdomen is distended and tender along the course of the 



The Practice of Osteopathy 533 

colon. The disease may abate here, recovery from the condition being 
slow; or the symptoms may increase in severity with persistent, small, 
painful stools, mainly of blood and mucus, tenesmus, and with scanty 
urine. The child grows pale and emaciated, and assumes a senile ap- 
pearance. These cases last five or six weeks, death being preceded 
by coma and convulsions; though a few recover. Relapses are not un- 
common and should be guarded against. Ulcerative and membranous 
forms may occur. Pneumonia and nephritis are possible complications. 

Diagnosis. — Enterocolitis is distinguished from dyspeptic diar- 
rhea by the greater severity, more fever, greater prostration, the stools 
containing more mucus and even blood, and by the greater pain and 
suffering. Cholera infant sins may be recognized by the abrupt onset, 
very high fever, constant vomiting, and early collapse. If typhoid fever 
seems a possibility, the Widal test should be used. 

Prognosis. — Grave; recovery follows prompt treatment with fav- 
orable surroundings. 

Treatment. — Attention should be given to the condition of the 
spine from the eleventh dorsal to the fifth lumbar. An inhibitory re- 
laxing treatment over the sacral foramina will lessen the tenesmus. When 
the ileum and colon are involved, disorder is usually present at the third 
and fourth lumbar vertebrae, although the lesion may be higher. Relax- 
ation of all muscles in this region and correction of the vertebral lesions 
are essential. 

Irrigation of the bowels once a day with a pint of cold water is very 
beneficial and even pieces of ice may be introduced into the rectum. 
Fresh, pure air, rest and cleanliness, with a restricted diet and daily warm 
baths are important. In a word, hygienic and dietetic treatment similar 
to that for acute diarrhea should be employed. 

In all forms of diarrheal diseases in children much depends upon 
previous osteopathic attention, diet, hygiene, and environment. 

Cholera Morbus 

Dehnition. — An acute, gastro-intestinal catarrh of sudden onset, 
characterized by violent abdominal pains, incessant vomiting and purg- 
ing. 

Etiology and Pathology. — This disease greatly resembles Asiatic 
cholera; so much so that one seems justified in suspecting that cholera 
morbus, hke true cholera, is due to a specific organism. No single bacillus 
has yet been designated as the specific germ, although one has been rec- 
ognized resembhng verj^ much the common bacillus of true cholera. 



534 The Practice of Osteopathy 

Until this has been fully decided, cholera morbus must be regarded as 
severe inflammation of the mucous membrane of the stomach and intes- 
tines, due to some poison generated from the improper food, which seems 
to be the cause of the disease, such as indigestible fruits, cabbage and 
cucumbers. It is most prevalent in hot weather, but is also caused by 
exposure to cold and damp. The condition of the mucous lining of the 
intestines is the same as in acute diarrhea. In fatal cases of cholera 
morbus there is the same shrunken, ashy appearance of the skin that 
characterizes cholera. 

Sympfoms. — The onset is sudden, with intense cramps in the epi- 
gastrium and frequently in the lower hmbs; nausea; vomiting, and purg- 
ing of bilious material, which later becomes alm'i^'^t like water, and in se- 
vere cases the discharge becomes serous, finally resembhng the rice water 
discharges of true cholera. There are also inteiise thirst, moderate fever, 
rapid emaciation and loss of strength ; the surface becomes cold and cov- 
ered with clammy sweat; the pulse is frequent and feeble. The patient 
becomes restless and anxio\is. 

Diagnosis. — Asiatic Cholera. — There is no way of distinguishing 
between Asiatic cholera and cholera morbus, except by examination of 
the discharges for the bacillus. Similar attacks are produced in poison- 
ing by arsenic, corrosive subhmate and certain fungi, and are only dis- 
criminated from it by chnical history and cause. 

Prognosis. — In the majority of cases the prognosis is favorable, 
death rarely occurring. The duration is from twenty-four to forty- 
eight hours. 

Treatment. — A strong inhibitory treatment to the gastro-intestinal 
nerves is at once demanded. This relaxes the muscles of stomach and 
intestines, dilates the blood-vessels and lessens peristalsis. The treat- 
ment should be kept up until rehef is given. In some cases, gentle treat- 
ment over the stomach and intestines quiets the distress. Inhibition at 
the occiput gives reUef, especially to the nausea and vomiting. Hot ap- 
phcations should be apphed to dorsal and lumbar spine. 

The vomiting is reheved principally at the fourth and fifth dorsal 
vertebrae on the right side near the angle of the ribs. Cold carbonated 
water and pieces of ice swallowed are useful. The diet must be regulated, 
the further after treatment being symptomatic. Clear the bowel by 
warm enema if any irritating matter is stiU present. 

Inasmuch as food passes through the small intestine in 4 to 6 hours, 
and requires 20 hours to pass through the colon, the colon should be 
emptied by high irrigation in all acute intestinal disorders. 



The Practice of Osteopathy 535 

Intestinal Colic 

This is a painful spasmodic contraction of the muscular layer of the 
intestines. 

Osteopathic Etiology. — Lesions of the splanchnics derange the in- 
testinal nervous mechanism, with a consequent upsetting of circulatory 
equalization and chemical function of the intestines. Thus irritations 
and obstructions of the reflex arc predispose to lowered resistance, con- 
gestions, and disturbed chemism. Indigestible food, flatulency and im- 
paction of feces oftentimes produce intestinal colic. Exposure to cold 
and emotional upsets may be factors. Foreign bodies, intestinal worms, 
abnormal amounts of bile discharged into the intestines, and reflex causes 
from diseases, as from the ovaries, uterus, liver, kidneys, etc., will pro- 
duce the disorder; also lead poisoning, syphilis, rheumatism, locomotor 
ataxia, chronic malaria and hysteria. 

Kerley says: "Children who take too much milk, too strong milk, 
or who take milk too frequently are the usual subjects of colic. Prob- 
ably the most frequent cause of colic is indigestion of the proteid of the 
milk; either the proteid is in excess or the child has poor proteid capacity. 
Not a few cases of colic are due secondarily to defective bowel action." 

Symptoms. — Severe paroxysms of pain, centering around the navel 
and diffused throughout the entire abdomen. The pain is of a piercing, 
cutting and twisting nature, reheved upon pressure. The abdomen is 
distended and the patient restless and continually changing his position. 
The attacks alternate with periods of complete quietude. In severe at- 
tacks the features may be pinched and the surface cold, with feeble pulse, 
vomiting and tense abdominal walls, all indicating incipient collapse. 
The duration of the attack is from a few minutes to several hours, eased 
at intervals and usually ending by a discharge of flatus. 

Differential Diagnosis.— In lead colic the history, the slate-colored 
skin, blue line on the gums, sweetish metalhc taste, constipation, slow 
pulse, retracted abdominal walls, and lead in the urine will designate 
this disease. Biliary colic presents pain in the hepatic region, radiating 
to the back and right shoulder; also jaundice, calculi in the stools and bile 
in the urine. Tenderness over the gall bladder is important. Nephritic 
colic is accompanied by pain radiating down one or both ureters to 
the inner side of the thigh, with retraction of testicle of side affected, 
oi- the labia, and blood, mucus, pus or calcuH in the urine. In uterine 
colic there is dysmenorrhea and pain in the pelvis. In ovarian colic 
there is extreme pain upon i)ressure over the ovaries, and hysteria. Ab- 



536 The Practice of Osteopathy 

dominal aneurism presents tumor, pulsation, bruit. In inflammatory 

and ulcerative disorders of the abdomen there is tenderness upon pres- 
sure, and fever. The pain of acute appendicitis is at first general, cen- 
tering in the right ihac fossa in about 24 hours. The X-ray may be of 
definite aid in renal and biliary conditions and various disorders, such as 
intestinal adhesions, angulations, etc. 

Treatment. — Relief of pain is the first indication and is best ac- 
complished by strong inhibition in the splanchnic region, which relaxes 
the spasm of the intestinal muscles, by normahzing the reflex arc. If 
disorders of the spinal column are located, it is of primary importance that 
they be corrected. In cases of irritation of the intestinal mucous mem- 
brane, a contraction of muscles of the spine will be found according 
to the area of the intestines involved, e. g., irritation of the mucous coat 
of the jejunum causes contraction of the muscles at the tenth and eleventh 
dorsals. It is a visceromotor, viscerosensory or viscerotrophic reflex 
sign. On the other hand, a lesion at the tenth and eleventh dorsals 
may produce colic or other disorders of the jejunum. The portion of the 
bowel affected, therefore, can be often told by noticing the places of mus- 
cular contraction along the spinal column. Generally the jejunum and 
ileum are the portions of the bowel affected in intestinal colic. The 
pain can frequently be controlled if in the jejunum, at the tenth and 
eleventh dorsals; if in the ileum, at the twelfth dorsal; if in the ileo-cecal 
region, including the vermiform appendix, at first to third lumbar; 
if in the colon, at the third to the fifth lumbar; and if in the rectum, over 
the sacral and coccygeal nerves. Occasionally the duodenum and jeju- 
num are reached bj^ nerves as high as the fifth dorsal (usually vasomotor 
nerves, not sensory), and the other portions of the bowel lower, ac- 
cording to their respective positions. The reHef is given by way of the 
splanchnics and sympathetics to the mucous (sensorjO coat of the in- 
testines, although inhibition relaxes intestinal muscles (motor nerves) 
and dilates blood-vessels (vasomotor nerves). Though precisely local- 
ized inliibition is of decided value, still if normal ahgnment, through 
adjustment, can be secured results are usually quicker and more satis- 
factory. 

Anterior treatment to the abdomen helps to reUeve the contracted 
fascia of the mesentery, with a consequent freeing of the circulation. 
It aids peristalsis of the intestines and expulsion of the irritating material. 
This probably produces considerable effect by way of the axone reflex. 
Direct treatment to the abdomen for the peristalsis reHeves also con- 
stipation, impactions and the enteralgia, the latter principally by firm 



The Practice of Osteopathy 537 

pressure. Peristalsis is also increased by stimulation of the vagi and in- 
hibition of the splanchnics. The latter treatment^ of course, is not given 
to relieve pain directly, but to facihtate the removal of irritating sub- 
stances if such are the source of trouble. If this does not produce a move- 
ment of the l^owels promptly, a warm enema will assist greatly. The 
cecum and sigmoid should not be overlooked. 

Flatulency can be reheved by direct pressure upon the solar plexus, 
which apparently removes obstructions to the abdominal nervous system 
(particularly the nerves of the digestive glands, as fermentation and 
flatulency are due to a disproportionate secretion of digestive juices) 
and thus the gaseous formations are absorbed. Additional treatment 
to the lower dorsal vertebrae and lower ribs to relieve nerve lesions and 
increasing both thoracic and abdominal circulation may be indicated. 

As stated in the etiology of intestinal coHc, the splanchnic nerves 
•contain not only sensitive fibers, but motor and vasomotor fibers as well. 
The same is true of the vagi nerves; they exert upon the intestines not 
alone a motor influence, but also a blood control; consequently, our work 
in a certain region can be for more than one purpose. Hot appHcations 
to the abdomen may be of benefit. And hot fomentations to the spine 
for 20 or 30 minutes (affecting reciprocal inneravtion) is often of great 
benefit. The diet should always be regulated for a few days at least. 



Constipation is an unnatural retention of feces from any cause. 
The following causes are frequently met with: A deficiency of the bile 
or other secretions that aid peristalsis; many acute and chronic diseases 
which lessen the secretions and impair peristalsis, such as anemia, hyster- 
ia, chronic affections of the hver, stomach and intestines and acute fevers ; 
•certain drugs and strong purgatives; strictures; concentrated food ; sed- 
entary habits, over-fatigue and neglect of the calls of nature. Atony 
-of the colon maj^ be caused by chronic disease of the mucosa and by gen- 
eral disease causing debihty. There may be weakness of the abdominal 
muscles, due to obesity and the distention of frequent pregnancies, or 
obstructions, such as displaced uterus, pregnancy, prolapsed cecum, 
sigmoid or rectum, and displaced coccyx. Constipation is really a symp- 
tom, in most cases, of some disease; many times it is about the only symp- 
tom observed. One has to take into consideration the many causes that 
would produce constipation when the treatment of a case is undertaken. 
1. See Philosophy and Mechanical Principles of Osteopathy, p. 190. 



538 The Practice of Osteopathy 

A disordered structure may be found in almost any region of a body, which 
would bear directly or indirectly in the causation of constipation. 

Irregular habits often bring on the most obstinate cases of consti- 
pation in later life. There may also be local causes, such as disturbances 
of the normal secretions, impairment of intestinal walls, due to inflam- 
mation, and mechanical obstructions caused by tumors, intussusception, 
twists, etc. Constipation in infants is usually caused bj^ errors in diet, 
but may be congenital. 

In all obstinate cases the X-ray should be employed in diagnosis. 

In the majority of cases lesions will be found in the vertebrae of the 
lower dorsal and lumbar regions, or in the lower ribs of either side. The 
lesions may affect the vascular supply and innervation of the intestines 
directly, or the lesion may cause the constipation by affecting some 
other digestive organ first. Lesions to the vagi affecting the peristalsis 
of the intestines are common. 

The usual symptoms are frequent stools, debility, lassitude, head- 
ache, loss of appetite, anemia, furred tongue and fetid breath. Serious 
symptoms may result in long continued cases, such as piles, ulceration 
of the colon, perforation, enteritis and occlusion. The fecal mass may 
become channeled and diarrhea may occur from the irritation. In long^ 
standing cases of constipation, if the patient suddenly develops diarrhea 
the rectum should be well examined to see if there are impacted feces 
present. Neuralgia of the sacral nerves may also be caused by impacted 
feces in the sigmoid flexure. 

Treatment. — Naturally, owing to the numerous etiological factors, 
each case is a special study and the treatment is necessarily varied. Many 
cases will present slight impaction of the bowels, a sluggish liver, spinal 
lesions and so on, which simply require a specific treatment and all the 
symptoms will be removed. On the other hand, constipation may be due 
to prolonged ill health and thus require a careful, systematic treatment, 
not only of the bowels, but of the entire system. Of primary importance 
in these cases is regulation of the diet, plenty of exercise, sufficient sleep, 
and regularity in going to stool at a fixed hour each day. The effect 
of attention to the latter point, in some instances, will be sufficient to 
pei-form a cure. Too much cannot be said in regard to the beneficial 
effect of systematic habits. 

Lesions may be found in the spinal column producing constipation 
from about the fifth dorsal to the coccyx, although principally the lower 
three dorsal and upper two lumbar vertebrae are at fault. Constipation 
may be caused by defects at any point in the intestines, and consequently 



The Practice of Osteopathy 539 

the sections of the spinal column sending nerves through the interverte- 
bral foraixdna to the several sections of the bowels should be examined. 
At any point from the fifth dorsal to the coccyx, certain vasomotor, 
motor and secretory nerves of the intestines may be affected by var- 
ious lesions. The vasomotor nerves keep up the vascular tone of the 
bowels, the motor nerves the peristaltic action and the secertory nerves 
attend to the intestinal juices. In constipation,, disorders of the spinal 
column are generalty found on the right side. There is no good reason 
offered as to why this is so.* In those cases where the liver is impaired, 
the answer might be because most of the nerves to the liver are on the 
right side, but the right side is just as often affected when the lesions are 
in the lumbar region and the nerve supply to the hepatic region intact. 
Dr. Still considered the fifth dorsal of importance. 

The vagi nerves have important bearing upon the motor apparatus 
of the intestines. Lesions in the upper cervical, involving intestinal fibers 
of the vagi, occur occasionally. Stimulation of these fibers increases 
the peristalsis of the intestines. Mechanical stimulation of the mid and 
lower dorsal region, as shown by osteopathic experiments, increases per- 
istaltic action and vasoconstriction in the stomach and intestines. 

The value of direct treatment over the intestines from the duo- 
denum to the rectum in most cases of constipation cannot be overesti- 
mated. It aids peristaltic action, removes impactions, stretches adhe- 
sions, strengthens weakened muscles of the intestines and abdomen, 
and in general gives tone to all of the abdominal organs. The treatment 
should not be given in a hap-hazard manner, but each effort should be 
for a definite purpose. Care should be taken not to bruise the intes- 
tines or other organs, as by gouging or severe punching; the flat surface 
and the palms of the hands should be used. This means that the part 
of the bowel involved should be treated intelligently, the osteopath reach- 
ing underneath the section and the patient drawing the bowels up and 
in. Obstructions and impactions of the gut, especially at the ileo-cecal 
and sigmoid i-egions, should be carefully corrected. At all angles of 
the gut, impactions and prolapses may occur. 



*There are several possible suggestions. (1) Developmental (See Mayo, Rela- 
tion of the Deve]opment of the Gastro-intestinal Tract to Abdominal Surgery. Jour. 
A. M. A. Feb. 7, 1920. (2) Owing to the appendix, cecum, ascending colon, duodenum, 
and biliary tract being frequently disordered. (3) Imbalance of muscular tension, 
owing to the muscles of the right side being often the -better developed. Muscular 
lesions and lymphatic involvement of the cervical region seem to occur oftener on 
the right side than on the left. 



540 The Practice of Osteopathy 

J. H. Sullivan^ makes the following observation concerning severe^ 
deep abdominal treatment: "I have noted that this often resulted in 
the reverse of good effects. In constipation, naturally then, I am chary 
about treating abdominalh^, confining my work principally to the biliary 
regions, the ileo-cecal and left iliac regions and have attained good re- 
sults when a promiscuous working of the abdomen had not so resulted." 
This emphasizes the point that specific treatment is as much indicated 
for the abdomen as it is for the spine. 

Frequently there will be found a spastic condition of the pelvic co- 
lon, often associated with congestion and adhesions. This probably 
sets up a reversed peristalsis. Treatment by inhibitory relaxation, with 
patient in knee-chest position, and adjustment of lumbar and innomi- 
nate lesions, is indicated. 

Direct treatment to the liver and biliary ducts is necessary in many 
cases, as the bile secretion is often defective ; thus a slowness or inactivity 
of the liver and bile ducts might cause costiveness. 

Some cases result from anesthesia of the rectum, due to pressure 
of the fecal matter collecting in the rectum. Simple dilatation of the 
rectal sphincters and a stimulating treatment through the sacral nerves 
will bring about a healthy activity of these parts. Occasionally the 
coccyx becomes displaced and produces paresis of the rectal nerves; or 
a displaced uterus or a tumor may produce the same result. 

The use of proper food is essential. Coarse food leaves a great 
amount of residue, and on the other hand, dainty food leaves but little 
residue, both causing costiveness. As a rule increase the amount of fruit 
and vegetables. The patient should drink considerable water, and the 
time is of importance. Have a glass of cool, not iced, water taken on 
arising and if breakfast is delayed suflficiently, another in half an hour. 
Most people do not drink enough water. Unless contraindicated eight 
or ten glasses daily should be insisted upon. An enema^ occasionally is 
indicated and is a great aid Avhen used, particularly in cases of paralysis 
of the intestines and in impactions. Correct breathing and out door 
life are beneficial. 

Treatment of the Constipation of Infants. — Repeated small 
enemata at a fixed hour each day will often be satisfactory but be cer- 
tain that the tissue is not irritated. Two ounces of tepid water at a time 
should be injected. Careful spinal treatment and massage to the abdo- 
men will be useful, as will slight dilation of the anus, which is usually done 

1. Journal of Osteopathy, May, 1900. 

2. For points on enema, see treatment imder Intestinal Obstruction. 



The Practice of Osteopathy 541 

with the Httle finger, but in obstinate cases a soap stick may be used. 
When there has been continued straining at the stool, the sigmoid and 
rectum will often be found prolapsed, causing a mechanical obstruction. 
With the finger well lubricated this can be corrected and often is all that 
is needed. These directions, with care in the foods, are usually sufiicient 
in any case not congenital. In chronic constipation Ruhrah outlines 
dietetic treatment as follows: "In infants see that they get sufficient 
fat and protein; well-cooked and sweetened oatmeal gruel is useful. 
Orange juice, baked apple, or prune juice taken on an empty stomach 
is of service. Olive oil, the malted foods, or malt extracts are useful. 
In older children fresh fruits, vegetables, and oatmeal porridge are of val- 
ue. Graham bread, dates, figs, and prunes may be used." 

Intestinal Obstruction 

(Ileus) 

This is due to a sudden or gradual closure of the intestinal canal at 
any point. Closure of the gut may be caused by strangulation, intussus- 
ception, twists and knots, abnormal contents, strictures, tumors, Idnks, 
spastic states, adhesions, etc. 

Strangulation. — This is the most frequent cause of acute obstruc- 
tion of the bowels. There may be stricture of the bowels due to inflam- 
matory processes producing bands or adhesions, or due to the adhesion 
of a bowel to an abdominal wound; a vitelline remnant, as a blood ves- 
sel, may remain and act as a strangulating cord, or in Meckel's diver- 
ticulum one end may be attached to a mesentery or abdominal wall and 
thus form a ring through which the gut may pass and become strangu- 
lated. 

Strangulation may take place through the foramen of Winslow or the 
foramen ovale, or between the pedicle of a tumor and the abdominal wall. 

Peritoneal pouches, mesenteric and omental sHts, adherent appen- 
dix or Fallopian tubes and diaphragmatic hernia may be other causes. 
An internal strangulation (hernia) may take place in the crural or inguin- 
al canal, in the umbilicus, in the sacro-sciatic notch or in the opening 
through which the infra-pubic vessels pass. In strangulation there is a 
constriction of a portion of the bowel causing an arrest of the circulation 
of blood at that point, and more or less stoppage of fecal matter of the 
intestine. 

In ninety per cent of cases the strangulated part is in the lower 
abdomen and sixty-seven per cent occur in the right iliac fossa, according 
to Fitz. 



542 The Practice of Osteopath"^ 

Intussusception or Invagination. — Intussusception is a slip- 
ping of a part of the intestine into another part immediately below it, 
as the slipping of a part of a finger of a glove or a coat sleeve into an- 
other part. The portion involved may be anywhere from half an inch to 
a foot or more in length. This produces compression and inflammation 
of the intestine, and obstruction to the intestinal contents. It occurs 
principally in children and is more common in males. 

Spasms of the intestinal muscles and perverted peristalsis are prob- 
ably the most common causes. One part of the bowel may be dilated and 
an adjacent portion contracted, thus allowing an invagination. Diar- 
rhea, habitual constipation and intestinal polypi are important exciting 
causes. Invaginations oftentimes occur just before death, probably 
due to irregular peristalsis. 

Following engorgement and inflammation of the invaginated portion, 
a tumor is usually present, and lymph is exuded which may cause the lay- 
ers of gut to adhere, so that the invaginated portion is firmly held. Ne- 
crosis and sloughing are then hkely to take place. 

Intussusception varies according to location and is named according 
to the part of the bowel involved. There are commonly recognized (1) 
Ileo-colic, when the ileo-cecal valve enters the colon. (2) Enteric, of the 
small intestines. (3) CoHc, of the large intestine. (4) CoHco-rectal, of 
the colon and rectum. (5) Rectal, of the rectum. 

Twists and Knots. — These occur more frequently in males, usually 
between the ages of thirty and forty. In nearly all cases the twist is ax- 
ial, accompanied by relaxed and lengthened mesentery. One portion 
of the bowel may be twisted about another, or a loop of bowel twisted 
upon its long axis. A bowel being impacted or overdistended by feces 
and gas, is quite likely to roll on its axis or knot and become dislocated, 
its weight and inactivity thus producing compression and obstruction 
of the bowels. The volvulus commonly occurs in the large intestine, at 
the sigmoid flexure and in the ileo-cecal and cecal regions. It occasion- 
allj' occurs in the small intestine. 

Abnormal Contents. — Obstructions may be caused by gallstones, 
enterohths, lumbricoid worms, certain medicines (such as magnesia and 
bismuth), fruit stones, coins, needles, pins, buttons, etc., and fecal mat- 
ter. Foreign bodies usually lodge in the ileo-cecal region and in the 
small intestine, while fecal impactions occur in the large intestine, more 
frequently in the lower part. Females are more subject to it than males. 

Its causes are many and are similar to those of constipation. Spinal 
1 esions are very frequent, probabl}- causing paresis or paralysis of a seg- 



The Practice of Osteopathy 543 

ment of the bowel; or all the foi'ces that maintain a normal activity of the 
intestines may become impaired. Hemmeter^ says it is "more frequent- 
ly the result of defective innervation of the intestine." 

Impactions are frequently met with and are easily overlooked 
under any diagnosis which does not include thorough palpation of the 
abdominal viscera. The impaction may be so large as to produce dila- 
tion of the bow^el. The obstructive mass becomes very hard and dry and 
perhaps channeled, allowing some material to pass until, finally a large 
piece of fecal matter will obstruct the passage completely. In diagnosis 
it must not be confused with neoplasms, tumors, etc. Impactions may 
occur at any point of the colon and the weight so drags the bowel out of 
position as to be misleading. The principal points are the ileo-cecal 
region, sigmoid flexure, and rectum. Tenderness is usualty present, as 
may be diarrhea which must not be taken as evidence that the bowel 
is clear. Impaction gives rise to many reflex symptoms and is often 
the real cause of many mistaken conditions. 

Too much cannot be said on the importance of a thorough examina- 
tion of colon and its connections, which should be routine of every examin- 
ation as the large bowel is impacted much more often than suspected and 
may be the seat of many reflex and direct disturbances. The heart may be 
affected by weight upon the vessels, gastric disturbances and signs oj 
autointoxication from absorption may appear. 

Dilatation of the sigmoid flexure, especially when it is congenitally 
long, may even be so great as to crowd up and interfere with the liver 
and diaphragm ; in these cases the coats of the intestines are usually hy- 
pertrophied. 

Strictures and Tumors. — These usually occur in adults, more 
frequently in women and generally involve the large intestine and lower 
part of the abdomen, most of them occurring in the left iliac fossa. They 
frequently result in chronic obstruction. Occasionally, a stricture may 
l^e spastic, due to vertebral lesions, that is severe enough to cause com- 
plete Vjlockage of intestinal contents. These are usually of the pelvic 
colon. There are cases where the opposite condition, paralysis of a 
section, generally of the small intestine, occurs. This may be due to 
injuries to the bowel, or to damage of the blood-supply, or to derangement 
of the innervation . 

Scar tissue, following ulceration of the bowel; tumors of various 
kinds; and congenital defects, are possible sources of intestinal obstruc- 
tion. 

1. Diseases of the Intestines, Vol. I, p. 240. 



544 The Practice of Osteopaths 

Symptoms. — Acute Obstruction. — There is constipation, nausea 
vomiting, and pain. The pain is of a colicky nature and may come on 
abruptly. After the contents of the stomach have been vomited, the 
material becomes colored with bile, and finally stercoraceous vomiting 
occurs. Observing the contents vomited (gastric, bile-stained, and fecal) 
will greatly aid in the diagnosis. The contents of the bowel, below 
the obstruction, may be emptied or complete constipation may remain. 
All the symptoms, as a rule, rapidly grow more pronounced. The pain 
is more severe; tenderness occurs over the abdomen in hmited areas; 
there is slight tympany; the eyes are sunken; the skin is cold and clammy; 
the pulse is quickened and feeble; there is rapid increase of leucocytes; 
the urine highly-colored; the tongue is dry and there is incessant thirst; 
tenesmus and tumor may be marked, and fever occasionally occurs. The' 
above condition may continue from three daj^s to a week, when collapse 
and death may occur, if rehef is not obtained. 

Chronic Obstruction. — In fecal impactions constipation of long 
standing is commonly observed. In some cases the fecal mass has be- 
come channeled, allowing the bowels to remain open; the patient possibly 
not knowing that there is any trouble. In fact, diarrhea may be present, 
due to irritation above the impaction. Finally, however, obstruction 
occurs; the breath is offensive, the appetite is poor, the abdomen swells, 
and there is fullness and weight within the abdomen, accompanied by pain 
and vomiting. Upon examination before complete closure, the fecal 
impactions can easily be felt through the abdomen externally. The 
tumor is a yielding mass. It has been mistaken for an enlarged liver or 
gall-bladder, a kidney, or a tumor of the stomach or duodenum. Other 
symptoms may be present as hiccough, jaundice, tenesmus, tumultuous 
peristalsis, local peristalsis, local peritonitis and collapse. In stricture 
caused by cicatrices that may have been formed years before, complete 
obstruction takes place. Transient attacks often occur. Usually the 
general health is greatly impaired long before complete occlusion. 

Diagnosis. — A diagnosis can usually be made by careful, thor- 
ough examination through the abdominal wall, in connection with the 
symptoms, and the physical signs. The region of intestinal trouble is 
manifested by contracted muscles at certain points along the spinal col- 
umn, corresponding with the particular portion of the bowel involved, 
as indicated under intestinal colic. Examining the patient in the knee- 
chest position will often give a better opportunity to locate and out- 
line the obstruction. Rectal and vaginal examinations should not be 
neglected. Intestinal obstruction may be confounded with tumors, 



The Practice of Osteopathy 545 

hernia, intestinal colic, enteritis, peritonitis, hepatic colic and renal colic. 
Peritonitis may be differentiated by the history, the early fever, diffused 
tenderness and absence of fecal vomiting. When invagination occurs, 
besides the symptoms of obstruction, the age, tenesmus, bloody discharges 
and the sausage-shaped tumor in the hne of the colon, will be diagnostic. 
In stricture, the history, gradual onset, and ribbon-like and bloody 
stools will distinguish that disorder. In tumors the gradual onset, age, 
bloody discharges, and cachexia will be important s.ymptoms. X-ray 
diagnosis may be of value in certain cases. 

Treatment. — Treatment of the bowels directly is required, and 
each case must depend for its rehef upon the ingenuity of the osteopath. 
Rules to be followed cannot be given, as cases vary in manner of involve- 
ment and in location, consequently the correction of the disorder depends 
as much upon the ability of the osteopath as does the determination of 
the diagnosis. Taxis is the method commonly used in relieving intestinal 
obstructions, though other methods may be employed. 

In invagination, raising the buttocks and lowering the chest, 
with thorough injection of oil or tepid soapsuds, or an inflation of the 
colon with air, may give relief. In addition to thorough but cautious 
manipulation of the bowels as in impaction, irrigation of the lower bowel 
with warm water, soapsuds, or glycerine and water, will usually be of 
material aid. In strangulation, high injections of warm water, and 
assuming the knee-elbow or lateral position, may straighten out the acute 
obstruction. Twists and knots are best relieved by direct treatment, 
although injections may be of aid. Kinks of the pelivc colon, ileum, and 
duodenum are best treated with the patient in the knee-chest position. 
Tumors and strictures will require, sooner or later, surgical inter- 
ference in most cases, but to treat as in impaction will be effective for a 
short time at least. If there is no indication of immediate relief witliin 
three days, surgical interference should be instituted. Besides 
the ordinary treatment for the nausea and vomiting, washing out the 
stomach will help allay such disorder, quiet the peristalsis and relieve the 
abdominal distention and pressure above the seat of obstruction. Strong 
thorough treatment of the spinal nerves to the stomach and intestines 
will be of great help in lessening pain, estabhshing normal peristaltic ac- 
tion and in suppressing inflammation. The vagi also should be treated 
for perverted peristalsis. Hot fomentations will be of service. The 
nutrition of the patient is best retained by rectal injections of food. 

Spastic states, particularly of the pelvic colon, frequently cause 
constipation of various degrees of chronicity. Reaching beneath the 



546 The Practice of Osteopathy 

spastic area and inhibiting and raising (knee-chest position) the part^ 
will often give marked relief. 

Adhesions can often be stretched sufficient]}' to resore normal func- 
tion of the bowels. 

Treatment of impactions and abnorntal contents requires an 
additional word. The first step is to free the colon of tiie fecal mass. 
The enema is of great assistance in this, for cases of long standing present 
a hard, drj^ mass, often adherent, and the mucous membrane is sensitive 
from inflammation. Much abdominal treatment must not be given un- 
til the mass is softened by water. When in the sigmoid or rectum it 
may, if not dislodged by repeated enemata, have to be removed by a colon 
spoon, perhaps under anesthesia. Impaction of the small intestine is 
rare and out of reach of the enema, although if taken as hot as can be 
borne, it will exert considerable influence high up. In these tendencies 
and in constipation, when the bowel must be kept open before treatment 
has produced much effect, there should be an effort made to break up any 
cathartic habit which may be formed. The enema is a most valuable aid, 
but it must be given correctly. The patient should be instructed that a 
fountain syringe is preferable, and that it must never be taken standing. 
This merely fills and distends the rectum, or lower sigmoid at the best, and 
is passed without any or with very little effect. Lying on the right 
side is a very good position, as is also on the back with hips elevated, but 
the knee and chest is best in most cases. The water should be a Httle 
above body temperature and can be saponified or used clear. The 
effect will be about the same. The tube should be perfectly smooth and 
well lubricated and introduction must be made with care so as not to 
bruise or irritate. The water, having been allowed to run to expel the 
air, may be now started and will separate the mucous folds and allow easy 
penetration. The rubber tube should be held between the thumb and 
finger, so the flow can be stopped as soon as it meets an obstruction. 
When this is passed the flow can begin again and continue until the re- 
quired amount (from one to two quarts for an adult), has been taken, 
or until the feeling of distention becomes too great. By following this 
method, much of the distress and cohcky pains which sometimes ac- 
company an enema, ma}^ be avoided. Water should be held for some 
minutes, to allow softening of the fecal mass. In many impactions it 
is important to get the water into the ascending colon. For that pur- 
pose nothing is better than a Coles sigmoid irrigator. This is shaped 
somewhat like the letter S and is about a foot long from tip to tip. Its 
introduction is not diflScult, but care must be used. Place the patient 



The Practice of Osteopathy 547 

on the right side and stand in front, having the bag suspended near. 
Introduce the tube and with slow, gentle pressure let it follow the course 
of the bowel. When the splenic flexure is reached, it will stop, but by 
letting a Httle water flow, the bowel will distend and it will pass. When 
in the full length, the end will be near the median hne and in the trans- 
verse colon. Now let the water flow slowly, stopping frequently, and 
with one hand gently hft and work the abdomen. This will both soften 
the contents and aid the water in reaching the farthest point. It is not 
well to give more than a quart the first time, as there is apt to be some pros- 
tration. The tube also has the mechanical effect of raising and replacing 
the sigmoid, descending colon and splenic flexure. When there is lack 
of tone to the bowel or when very_ little stimulus is needed, a half pint 
of cold water taken in the morning, will often act quickly. Appliances 
which force the water into the bowel when the patient is sitting, are not 
recommended, as they tend to stretch the muscular coat by pressure 
from lifting a column of water. 

Hernia. — There are several methods of replacing a hernia. The 
first endeavor, in every instance, must be to reduce it, whether it be 
strangulated, incarcerated or simply protruded. One of the easiest and 
commonest methods is to place the patient on his back, the buttocks ele- 
vated, the legs flexed upon the thighs, the thighs flexed upon the abdomen, 
and the limb on the affected side slightly rotated inward, so that the col- 
umns of the ring about the hernia may be relaxed. After the hernia is 
protruded a little more, so that its contents may be emptied readily, a 
gentle pressure with the thumb and finger is made upon the upper part of 
the tumor, when the rest will follow. A gurgling noise is heard upon 
reduction. Cases that cannot be reduced and are causing acute ob- 
struction of the intestines, should be treated surgically. Incomplete 
hernia, which does not show externally, may be present and cause severe 
reflex symptoms. Considerable attention has been given to this by some 
investigators. The patient is placed in the Trendelenburg position and 
the bowel lifted out of the fossa. If any signs of hernia are present a 
well fitting truss will often cause it to heal. Exercises,in a few instances, 
will be beneficial. 

Appendicitis 

Appendicitis is an inflammation of the appendix vermiformis. 
In a few cases the cecum and surrounding tissues are involved (typhlitis, 
p(n'ityphlitis) . The vasomotor nerve supply comes from the lower three 
dorsals and upper two lumbars. The sensory nerves make their exit from 



548 The Practice of Osteopathy 

the three lower dorsals. Appendicitis is nearly always predisposed by in- 
jury to the innervation of the vermiform appendix and immediate region, 
vertebral derangements or sub-dislocations from the tenth dorsal to the 
third lumbar. The vermiform appendix is a peculiarly constructed or- 
gan, and its function has not been determined with positiveness. It 
undoubtedly has a function and possibly a very useful one. Sir William 
Macewen^ does not share in the general belief that the appendix is with- 
out function, but protests against its indiscriminate removal, believing 
it has a powerful influence over the function of the colon. "Yet thous- 
ands have been operated and show no ill effect. " Tliis is in keeping with 
the ideas of Dr. Still, who always maintained that the appendix is of 
importance to the human economy. Although the organ has been found 
in various localities of the abdomen, this fact and others do not necessar- 
ily indicate that it is a functionless relic. It is richly supplied with lym- 
phatic and blood-vessels and has a peristaltic action pecuHar to itself. 
When the organ is in perfect condition, foreign material probably would 
not find a lodging point in it, on account of its peristalsis. Dr. Still^ 
suggests that the appendix has a sphincter, also the power to contract, 
dilate or shorten, should any foreign substance enter, and he worked 
with this idea in view with uniform success. The truth of this theory 
has been proved by Abrams'^ who has demonstrated by the aid of the 
fluoroscope that peristalsis of the appendix can be stimulated by purcus- 
sion at the 10th dorsal and it made to empty and fill itself. Abrams makes 
use of this fact in the treatment of catarrhal appendicitis. Appendi- 
citis may also be caused by fecal impactions and foreign bodies in the 
bowel contiguous to the appendix. In these cases there is usually an 
impaired innervation from the spine, due to vertebral and lower rib lesions, 
resulting in a weakened muscular coat and catarrhal congestion of the 
mucosa. In a word, prolapse of the bowel at this point is a predisposing 
conmion cause. In various instances abrasions of the coats of the tube 
occur, or the innervation or vascular supplj'- is impaired, and pathogenic 
bacteria, as bacilli coli communis, streptococci pyogenes, staphylococci 
pyogenes aureus, typhoid baccilh, tubercle bacilli and others, find a favor- 
able lodging point and determine the nature of the disease. Injuries to 
the spinal column and displacements of the vertebrae in the lower dor- 
sal and lumbar regions, straining and lifting, tight lacing, torsion of the 
appendix, traumatism, impaction of feces, concretions and foreign bodies, 

1. The Lancet, (London,) Oct., 1904. 

2. Philosophy of Osteopathy, p. 226. 

3. Medical Record. 



The Practice of Osteopathy 549 

acute indigestion, indigestible food, overeating, exposure to wet and cold, 
and infectious diseases (as typhoid fever, tuberculosis and influenza), 
are all in the Kst of causes of appendicitis. 

Pathologically, in most cases the inflammation is catarrhal. This 
includes many of the mild attacks. The mucosa is inflamed similarly to 
catarrhal processes elsewhere, although the inflammation may rapidly 
spread to the deeper structures unless immediately cared for. The 
inflammation may be so severe that the lumen becomes closed. This 
is termed obliterating appendicitis. When this occurs the attack 
may cease and danger from subsequent attacks are at an end, but in- 
flammation may go on to purulent involvement and even to ulceration, 
gangrene and perforation or peritonitis. An abscess may be within 
or without the appendix. Adhesions are likely to form about the mass. 

Symptoms. — A sudden, violent pain in the abdomen, usually 
locaHzed in the right iHac region, although at first this pain may be gen- 
eral. The point of greatest tenderness is detected over McBurney's 
point — a point at the intersection of a line between the umbilicus and the 
anterior iliac spine, with a second drawn along the outer edge of the right 
rectus muscle. The patient usually lies on the back with the right leg 
drawn up. The severity of pain is not indicative of the seriousness. 
If the pain ceases suddenly, it is commonly a serious indication. There 
is usually fever at the onset, the temperature being from 100 to 102 or 
even 104 degrees F., and ver}^ rarely preceded bj^ a chill. In favorable 
cases the temperature gradually falls, reaching normal in from five to 
seven days. If recovery has not begun by this time an abscess is prob- 
ably forming. If suppuration takes place the temperature continues 
with but shght fall, although in some cases there is a rise, or it may be- 
come almost normal. Pain in the right iHac fossa, without fever, rarely 
points to an acute attack of appendicitis. Vomiting and nausea are more 
or less frequent, and more commonly present in the event of perforation 
or rupture of an abscess. In favorable cases vomiting rarely lasts be- 
yond the second day. In the majority of cases constipation is present 
from the beginning of the attack, due to paralysis of the bowels. There 
may be diarrhea, particularly in children. 

"Urine is febrile in character with large quantities of indican. The 
blood shows leucocytosis. A leucocyte count of 20,000 is high and 
indicates an acute appendicitis, with pus, gangrene or peritonitis." 

On Inspection of the abdomen at the onset of the attack, the sides 
look ahke, but on palpation there is rigidity of the rectus abdominis 
muscle and the other muscles overlying the seat of inflammation. The 



550 The Practice of Osteopathy 

whole abdomen may be slightly distended. In the majority of cases 
there is a progressive development of a hard swelling or tumor in the 
right iliac fossa. These tumors vary in size, but are usually oval and the 
size of a hen's egg, and generally situated a little above Poupart's lig- 
ament. Fluctuation of the tumor is indicative of suppuration. There 
is often great irritability of the bladder and frequent micturition. A 
sudden fall in the temperature often indicates that a perforation has 
taken place, or that a small abscess has ruptured into the intestines. 
In favorable cases the temperature falls at the end of the third or fourth 
day, the pain lessens, the tongue becomes clearer and the bowels are 
moved. If the tumor persists, the patient is veiy liable to have a re- 
currence of the condition. 

Rapid growth of the tumor and aggravation of the several symp- 
toms point to suppuration, especially extreme tenderness over the point 
of inflammation. If the appendicitis goes on to suppuration, there is dan- 
ger of rupture into the peritoneum. In a few cases the abscess may 
rupture into the bowel, in which case the patient recovers. Other ter- 
minations are lumbar abscess, hepatic abscess and perinephritic abscess. 
Death may be caused by septicemia or pylephlebitis. These events may 
be delayed a variable length of time, depending upon the extent and 
strength of the adhesions that form about the abscess. "The gravity of 
the appendix disease Hes in the fact that from the very outset the peri- 
toneum may be infected; the initial symptoms of pain, with nausea 
and vomiting, fever, and local tenderness, present in all cases, may in- 
dicate a wide-spread infection of this membrane." (Osier). He also 
says local signs are not so trustworthy as the general symptoms. 

There is Habihty to relapse in appendicitis. The attacks may 
recur for years at different intervals. In some cases these intervals are 
very short. In some cases perfect recovery may take place after re- 
peated attacks. 

Diagnosis. — In many cases the diagnosis is easy, but other cases 
require careful study and close observation. Sudden pain becoming 
localized, tenderness and rigidity in the right iliac region are three symp- 
toms that together almost positively indicate appendicitis. The leu- 
coc3^te count is of particular value. A pseudo-appendicitis, with all 
symptoms of true appendicitis in the initial stage, may be caused by the 
downward dislocation of the twelfth rib on the right side, and occasion- 
ally the eleventh rib on the same side. The rib lies obliquely downward 
toward the crest of the ilium. In a few cases the obhquity of the lower 
rib is so great as to very nearly touch the ilium. The dislocated rib may 



The Practice of Osteopathy 551 

produce severe irritation, pain, tenderness, rigidity, and even inflam- 
mation, of the abdominal muscles. The patient nearly always complains 
of the pain being deeply seated, thus possibly confusing one. In typhoid 
there is a gradual development of the fever, characteristic temperature 
curve, enlargement of the spleen, epistaxis and diarrhea. The Widal 
test should be made. The absence of fever and intermittent pain in the 
abdomen, with complete constipation, fecal vomiting, general disten- 
tion of the abdomen, bloody stools and marked tenesmus would determine 
intestinal obstruction. In tubal disease a gradual onset, a more dull 
and constant pain, the history, and pelvic examination will usually differ- 
entiate this disorder from appendicitis. Kelly^ gives these points in 
differential diagnosis, between acute salpingitis and appendicitis: "In 
the former it will usually be found that there has been a yellowish vaginal 
discharge for some period before the attack. The local pain and tender- 
ness, usuallylocated deeper in the pelvis, is most intense on palpation 
in the region of Poupart's ligament. On vaginal examination exquisite 
tenderness is felt on either side of the uterus." In biliary colic 
the pain is higher along the biliary ducts and gallbladder, extending even 
as high as the shoulder, and jaundice is generally present. In renal 
colic the pain extends along the ureters down to the inner side of thigh 
and testicle, and back into lumbar region. There is absence of fever and 
rigidity. The pain in perineplsritic abscess is downward into groin, 
as in nephritic colic, and there is tenderness of the lumbar region. Ex- 
ploratory incision may be necessar3^ 

Prognosis. — Naturally, the prognosis depends upon the character 
of the appendicitis, but on the whole the prognosis is favorable. A 
large proportion of cases revover. Surgical operations are many times 
deferred until too late; undoubtedly on account of the uncertainty of the 
condition. Still, on the other hand, many serious cases recover under 
the proper treatment when an operation seemed almost absolutely neces- 
sary; all going to prove the fact that very much depends upon diagnosis 
of the true condition. The statement that there is " no medical treatment 
for appendicitis, " seems rather broad in view of the report of the medical 
inspector" of the French Army in Algeria. Out of 668 patients suffering 
from appendicitis, 188 were operated upon and 23 died, while 408 were 
treated medically and only three died. He concluded that a meat diet 
tended to increase the number of cases. "It is exceedingly common 
and the prognosis is, on the whole favorable. Tafft, of Copenhagen, 

1. The Vermiform Appendix and Its Diseases, p. 711. 

2. Dr. Chauvel, 1902. 



552 The Practice of Osteopathy 

found adhesions in the neighborhood of the appendix in 35 percent, of all 
bodies subjected to post mortem examinations^. 

Treatment. — Confine the patient in bed at once. Cases have 
undoubtedl}' been lost by not enforcing this point. Attempts should 
be made to correct the disordered condition of the dorsal and lumbar 
regions. Thorough and careful treatment should be given at this point, 
and in most instances the pain can be relieved by correction of the dis- 
ordered vertebrae. If the case is seen at the beginning of the attack, 
careful manipulation that especially lifts the cecum and surrounding 
structures and local application of ice are indicated. However, great 
care should be exercised here, for some of the most severe cases show 
no induration. Temperature, pulse, and blood picture are invaluable 
as guides. When the case is advanced, extreme care should be used in 
manipulating over the swollen and inflamed region. Hot applications 
will be helpful in such instances. 

When due to fecal impaction and foreign bodies, thorough, direct, 
elevating treatment over the involved region, and high rectal injections 
are indicated. This applies to the onset, for if the disease has progressed 
to the point where pus may ])e present, the bowel must be absolutely 
at rest. Do not give or allow to be given purgatives at any stage of 
the disease. When sure that there is no pus, direct, careful work over 
the cecum and appendix is allowed and is of value. It should be a hfting 
of the colon and relaxing of nearby tissues, to promote the circulation. 
Treatment of the spine is necessary in all cases, to relieve pain, to cor- 
rect the nerve and vascular supply, and to increase peristalsis so as to 
remove irritating bodies- from the vermiform appendix. "Colitis follows 
appendectomy more frequently than any other abdominal operation. 
The explanation for this is that the appendicitis is seldom localized in the 
appendix but is complicated by coHtis, or rather the colitis is complicated 
by the appendicitis. In such cases, removal of the appendix aggravates 
rather than alleviates. A conclusion to be drawn is, to carefully palpate 
the colon in all appendicitis cases and reserve diagnosis, prognosis and 
advising of an operation until it can be definitely determined as to the 
location, extent and degree of the disease. The formation of pus is an 
indication requiring immediate evacuation. 

"If good surgical advantages are available and the case begins 

with considerable virulence and a surgeon can be had within the first 

twenty four hours, it is in all probability best to operate ; but if the case 

begins slowly or no good hospital advantages are available, or if the case 

1 . Rose and Carless. 



The Practice of Osteopathy 553 

is not seen until some forty eight hours have elapsed after the onset, in 
all probabihty it is strictly an osteopathic case and should not be touched 
by surgery. Some advocate in all instances to wait until pus is formed 
before operative procedure is resorted to. This is a rather dangerous 
attitude to take, for I have seen hundreds of cases operated and have 
operated upon a great many myself and I have never seen a case die unless 
it was a pus case." — S. L. Taylor.^ 

The case should be most carefulty watched, and a surgeon should 
be promptly called for consultation if the occasion demands it in the 
least; and if thought advisable, operation should be resorted to before 
too late. Do not assume too much responsibility in these cases. The 
patient should be nourished on a restricted diet of milk and animal broths. 
A.sa Willard^ strongly recommends no food by mouth, as it is bound to 
set up peristalsis and cause increased irritation. He sustains the strength 
by rectal feeding. This view is held by other authorities, even to with- 
holding water when the inflammation is at its height. Tasker confirms 
the advisability of restricted feeding and advises resting the bowel even 
to the point of discontinuance of food. The course of the attack is usu- 
ally so short that there is no danger of starvation and little loss of strength 
results. This point is a highly important one in cases of any degree of 
severity. 

In chronic cases of a fibrotic character, no pus, carefully lifting the 
parts and loosening adhesions in addition to spinal adjustment will 
often restore normal circulation. These conditions aside from the local 
disorder frequently cause hyperchloridia and other digestive disturbances. 

Diseases of the Liver and Bile Duct 

Primary diseases of the liver will invariably present osteopathic 
lesions from the fourth or fifth dorsals to the eleventh or twelfth. The 
ribs on the right side are commonly involved. These lesions probably 
disturb the Hver by way of the vasomotor fibers. Displacements of 
the duodenum, of the hepatic flexure and transverse section of the colon 
and displacements of the right kidney are frequent sources of Hver dis- 
orders. Care should be taken in differentiating primary from secondary 
diseases, for naturally the relative importance of the various factors in 
treatment will vary. In many secondary diseases there will be found 
predisposing osteopathic lesions, and these secondary disorders and de- 
generations can at least be palliated and occasionally the degeneration 

1. Clinical Osteopathy. 

2. Journal of the American Osteopathic Association, Dec, 1902. 



554 The Practice of Osteopathy 

retarded or stopped by persistent osteopathic treatment, diet, and hy- 
gienic measures. 

Hyperemia of the Liver 

This is an abnormal fulhiess of the blood-vessels of the hver, followed 
by an enlargement of that organ. It is active when there is abnormal 
pressm'e in the portal veins (afferent vessels); passive when there is 
excessive pressure in the sublobular veins (efferent vessels) . 

Osteopathic Etiology and Pathology. — Active hyperemia is 
usually due to indiscretions in diet. After each meal a physiological 
hyperemia of the hver occurs, which is greatly increased by habitually 
overeating and overdrinking. This condition may lead to fimctional 
disturbance and possibly to organic change. Traumatism and lesions 
of the vertebrae and ribs, irritating vasomotor nerves, are important. 
Habitual constipation, malaria, heat, and arrested menstrual epoch, 
and infectious fevers are also causes of the active form. Enteroptosis 
is not a rare cause. 

Passive hyperemia is due to obstructions of the efferent circulation. 
Valvular heart disease is the most common cause. Lung diseases, as em- 
physema or cirrhosis; obstruction to the vena cava or interference 
with the flow of blood through the liver; and diseases of the pleura, are 
among the causes. 

Most cases of congestion of the liver present lesions to the vasomotor 
nerves of the liver, fifth to ninth dorsal. Especially are the ribs over the 
liver apt to become displaced and affect the organ. 

Pathologically, the hver is enlarged and engorged with blood. 
The appearance of the organ depends upon the duration of the hyperemia. 
In passive hyperemia the central portion of the lobule and the area of the 
hepatic vein are deeplv colored. The periphery and the area of the por- 
tal vein are pale. This alternation of the dark and hght color gives rise 
to the nutmeg liver, which is so noticeable upon section. In cases of 
long standing, atrophy of the liver cells and overgrowth of connective 
tissue result. 

Symptoms. — Active Hyperemia. — Dull aching and a sense of 
fullness in the right hypochondrium, aching of the hmbs, coated tongue, 
nausea, vomiting, constipation, highly colored urine, and slight jaundice. 

In passive hyperemia the symptoms are the same, but less marked. 
The onset is gradual and the liver may attain considerable size. In 
severe cases following tricuspid regurgitation the liver may pulsate. In 
severe cases dropsy takes place. 



The Practice of Osteopathy 555 

Diagnosis. — Active hyperemia is occasionally confounded with 
vjatarrhal jaundice. Usually congestion of the liver is easily diagnosed. 

Prognosis. — In active hyperemia the prognosis is good, unless 
repeated attacks lead to atrophic degeneration. In passive hyperemia 
the prognosis depends entirely upon the cause. 

Treatment. — Active hyperemia. — The treatment consists of 
measures which tend to diminish the congestion, principally a thorough, 
direct manipulation over the liver by raising and spreading the ribs. 
Careful and thorough treatment to the dorsal splanchnics of the Hver is 
also indicated. The substitution of a scanty for a heavy diet is essential. 
The foods given should be such as are easily digested, as milk and broths; 
fats and sugars are to be avoided. 

In passive hyperemia the treatment consists of correcting the 
disorder causing it. Often heart diseases are the cause. A thorough 
depletion of the bowels will aid largely in relieving ascites that may fol- 
low passive congestion (See ascites). 

In liver congestions it is well to pay attention to the intestinal con- 
dition in order that the circulatory mechanism here may be thoroughly 
coordinated with the hepatic. 

Simple Catarrhal Jaundice 

Definition. — Jaundice due to inflammation of the terminal portion 
of the common duct, not the result of impacted gallstone. The disease 
probably starts as a catarrhal inflammation of the stomach and upper 
portion of the small intestine. The bile is retained and absorbed. 

Osteopathic Etiology and Pathology. — A frequent predisposing 
cause is the subdislocation of the tenth rib on the right side, thus inter- 
ferring with the innervation to the bile ducts, and causing congestion of 
the mucous membrane of the common duct; although lesions above and 
below this point may occur. Extension of gastro-duodenitis into the 
common duct is a common source of the inflammation. Sagging of the 
duodenum will disturb the bile-duct through its being a portion of the duo- 
deno-hcpatic ligament. Duodenal catarrh usually follows errors in diet, 
exposure, malaria, Bright's disease, portal obstruction and chronic heart 
disease. Infectious fevers, as pneumonia and typhoid fever, and emo- 
tional disturbances are among the causes. Catarrhal jaundice may occur 
in epidemic form. 

Pathologically, the duodenal end of the duct is most commonly 
involved. The mucous membrane is swollen and the orifice fills with 
mucus. The inflammation may involve the common and cystic ducts 



556 The Practice of Osteopathy 

and even the hepatic. The liver is enlarged and the gall-bladder dis- 
tended. 

Symptoms. — The only symptom present may be simply the jaun- 
dice. There is always tenderness upon pressure over the ducts. The 
patient many times complains of a stabbing pain when pressure is exerted 
over the duodenal opening. Usually the course of the bile duct can read- 
ily be felt upon deep pressure, owing to the tumefaction. Accompany- 
ing this condition may be general malaise, loss of appetite, nausea, vomit- 
ing, constipation or irregular action of the bowels, pains in the back and 
limbs and a slight fever. 

Diagnosis. — Where jaundice is present witliout pain, it generally 
indicates catarrhal jaundice. The absence of emaciation or of evidences 
of cancer or cirrhosis usually makes the diagnosis easy. Good general 
nutrition and a negative physical examination favor simple jaundice as 
to the diagnosis. 

Prognosis.— The prognosis of catarrhal jaundice is favorable, un- 
less accompanied with infectious diseases or hypertrophic cirrhosis. 
When diseases are associated with jaundice the danger is usually from the 
disease. The duration of the disease is generally given as from two to 
eight weeks, but osteopathic treatment generally lessens that time at least 
one-half. 

Treatment. — The treatment is directed toward relieving the in- 
flammation of the bile ducts and increasing the flow of the bile into the 
intestines. Great relief to the patient will be experienced from thorough 
treatment over the bile ducts, especially at the duodenal end. Press 
slowly but firmly over the region of the ducts, then execute a downward 
motion with firm pressure over the course. This performance should be 
repeated several times, until the tenderness in this region is almost or 
entireh^ relieved. The idea of this treatment is, first, to slowly but firmly 
bear down upon the abdominal muscles over the congested tissues, so as to 
relax the tissues and get as close to the ducts as possible, and second, 
with the downward movements to reduce the congestion of the ducts 
and at the same time to remove any mucus or other material from the or- 
ifice, thus allowing a freer flow of bile. It will be recalled that the nor- 
mal flow of bile is under very low pressure. Care should be taken not to 
gouge or dig into the tissues with the ends of the fingers, but to use the 
flat surface of the fingers. Any gouging or severe treatment will not 
allow one to accompHsh his purpose, owing to the stimulus or irritation 
it would give the abdominal muscles and thus cause them to contract; 
and furthermore, it would more or less bruise the parts. An inhibitory 



The Practice of Osteopathy 557 

treatment should be given along the spine on the side affected to help 
relax the abdominal muscles before this treatment is administered. In 
all circulatory disturbances of the bile-duct and other hepatic tissues 
lift the duodenum at about the second lumbar where it lies beside the 
ascending colon. This tends to release portal vein, hepatic artery and 
bile-duct, the duodeno-hepatic ligament. 

Direct treatment is given to the liver by more or less kneading 
or working the organ and also by raising and spreading the ribs. This 
treatment is to stimulate the activity of the liver. Reaching under the 
cartilages of the eighth and ninth ribs on the right side and bearing in- 
ward and downward will empty the gall-bladder and thus be of aid in 
relieving the tension in the biliary passages. It is probably a stimulus 
to these cutaneous fibers that causes a relaxation of the sphincter muscles 
of the gall-bladder and thus allows it to empty. Stimulation of the tenth 
nerve contracts the gall-bladder. Then it should also be noted that work 
over the duodenal end of the bile-duct relaxes the orifice while through 
reciprocal relationship the fibers of the gall-bladder contract. When 
all of the muscles of the hepatic region have been carefully relaxed and 
softened, a thorough examination can then be made of the vertebrae 
and ribs that might embarrass the innervation or vascular supply of the 
liver. Lesions of the vertebrae and ribs affecting the liver may occur 
from the sixth to the eleventh dorsal. Lesions to the vagus and phrenic 
nerves may occasionally involve the organ. 

Irrigation of the large bowel with cold water ma}^ be employed. 
The cold excites peristalsis of the gall-bladder and ducts. Drinking 
freely of water will be helpful. A non-stimulating diet should be given. 
The stomach ma}^ not be in a condition to bear solid food; and further- 
more, food on entering the duodenum will increase the local inflammation 
of the common bile duct. Give diluted milk, buttermilk, light meat- 
broths, clam-broth, egg albumin and pressed beef juice. After the 
pain, vomiting and fever subside, the diet can be gradually increased. 

Cholecystitis 

Cholecystitis is an inflammation of the gall-bladder caused by in- 
fection. Stagnation of bile due to obstruction (especially gall-stones) of 
the bile-ducts, or a slowing of the bile flow owing to deranged innervation 
from osteopathic lesions or sagging bowel, are predisposing factors. 
Fibrotic changes in the appendix are fairly common sources that derange 
the nervous reflexes of the biliary function. The disorder may be associ- 
ated with specific fevers. 



558 The Practice of Osteopathy 

Exciting factors are the colon bacilli, streptococci, staphylococci, 
tjqDhoid bacilli, and pneumococci. 

Symptoms. — The gall-bladder feels hard and full. There is in- 
flammation and thickening of the mucous membrane, with considerable 
increase of mucus. Owing to the infection there may be ulceration and 
suppuration, with possible perforation and peritonitis. When the in- 
flammation extends outside of the bladder there are usually adhesions. 

The onset is commonly sudden, with pain and tenderness in the 
right hypochondrium. Great care should be taken in deciding the loca- 
tion of the inflammation, for the pain and tenderness may be over the 
stomach, or along the duodenum or ascending colon as low as the cecum. 
Nausea, fever, constipation, and possibly jaundice, are other symptoms. 

Treatment. — Exercise special care in treating these cases. Al- 
though in many instances the inflammation will rapidly subside, still 
owing to suppuration there is danger of aggravating the condition. It 
is better, in doubtful cases, to confine the treatment to spinal work, and 
to influence drainage by placing the patient in knee-chest position and 
carefully raise cecum, ascending colon and duodenum. Rest, restricted 
diet, plenty of water, and hot fomentations will be beneficial. In severe 
cases surgical interference is indicated. 

Jaundice 

(Icterus) 

Jaundice is a symptom and not a disease. It consists of the dis- 
coloration of the skin and other tissues by material derived from the bile. 
The discoloration may vary from a mere paleness to a yellow or brown 
olive hue. 

Toxic jaundice occurs in acute yellow atrophy, pernicious anemia, 
P3^emia, specific fevers, and the action of poisons. 

Obstruction by foreign bodies as gall-stones and parasites are im- 
portant causes. Inflammation and swelling of the biliary ducts and duo- 
denum are common causes as well as stricture of the duct by tumors and 
various growths, either internal or external, to the biliarj^ ducts. In 
some instances pressure from without by the pancreas, stomach, kid- 
neys, enlarged glands, fecal matter, a pregnant uterus, etc., has been 
the cause. Irritations and obstructions of the splanchnic nerves, due to 
lesions in the lower dorsal vertebrae and the ribs from the sixth to the 
eleventh, will often markedly affect the liver. Also lesions at these points 
may predispose to inflammation and tumefaction of the bile ducts. 



The Practice of Osteopathy 559 

Symptoms. — Besides the discoloration of the skin, there is itching 
of the skin, on account of bile pigment deposits; even eruptions may occur. 
The mucous membranes are often colored and a constant symptom is 
the bright yellow discoloration of the sclerotic coat of the eye. The 
secretions are colored. It may be first noticed in the urine. The per- 
spiration is colored, rarely the saliva and tears. There is frequent sweat- 
ing. 

As very Kttle bile passes into the intestine, the feces are pale and 
gray, and sticky. The bowels are generally constipated, but diarrhea 
may occur, owing to decomposition resulting from absence of the nor- 
mal ingredients. Other symptoms may be associated with the gastro- 
intestinal derangements, as nausea, fetid breath and loss of appetite. 
A slow pulse may occur, due probably to some stimulating effect on the 
inhibitory action of the vagus nerve. Lesions are often found at the 
atlas and axis, affecting the vagus. Pain back of the right scapula is a 
symptom of Uver trouble; it has been suggested that it is due to a stim- 
ulus passing up the vagus to the spinal accessory, and thence to the 
trapezius muscle. 

Various cerebral symptoms may be present, as great depression, 
irritabihty, headache and vertigo. In severe cases there may be dehrium 
and coma. 

In hemolytic and toxic Jaundice the destruction of blood is due to 
some toxic agent. The feces are not clay colored and the urine is less 
stained with bile. The general sjaiiptoms may be very severe depending 
upon the underlying cause. 

Diagnosis. — To mistake for jaundice the dirty yellowish discolor- 
ation of the skin . commonly termed sallowness is an error often made. 
This condition indicates malaria, uterine disease or general ill health. 
Very likely it is an anemia and is readily diagnosed from the jaundice 
as the secretions and conjunctiva are not stained. Addison's disease 
somewhat resembles jaundice, but the feces are normal, the urine and 
sclerotic coat are not colored, but exposed portions of the body and flex- 
ures of the joints are deeply stained. 

Prognosis. — Depends entirely on the cause producing it. Ordi- 
nary cases run from two to six weeks, while others may not recover for 
several months. Jaundice from impaction of the bile ducts may be man- 
ifest for only a few days. Toxic form may terminate fatally, owing to the 
disease causing it. The extent of resorbtion of bile and destruction of red- 
blood cells in the liver varies to a considerable degree. 

Treatment. — The treatment for the different forms resulting sec- 



560 The Practice of Osteopathy 

ondarily will be found under the diseases causing them. A simple icter- 
us, caused by disturbance through the innervation of the liver and bile 
ducts directly, can be i-elieved readily by thorough treatment of the liver 
and bile ducts as described under catarrhal jaundice. Carefully raise the 
intestines if they are prolapsed, especially the colon and duodeniun. 

Cirrhosis of the Liver 

This is a chronic disease of the liver, characterized bj^ hyperplasia 
of the connective tissue with destruction of the Hver cells, resulting in 
the organ becoming hard and usually small. 

Etiology. — The disease usualty occm'S in the male sex and in middle 
life. When occurring in children, it is commonly of the syphilitic form, 
though it may be due to other infections. The abuse of spirituous liquors 
is a common cause. It follows chronic diseases, such as syphilis, long 
continued malarial intoxication, gout and tuberculosis. Passive con- 
gestion, due to chronic heart and lung disease, causes some cases. A 
few cases are caused by inflammation of the bile ducts, due to infection 
and obstructing calculi; others to a stimulating diet, while some cases 
are inexplicable. 

Pathologically, the first stage is hj^perplasia of the connective tis- 
sue and consequent enlargement of the organ. As this increases the con- 
nective tissue destroys immense numbers of the hepatic cells, owing to 
the pressure. Often the enlargement is accompanied by tenderness. 
In the later stage the overgrowth of imperfectly developed tissue seems 
to contract the hepatic cells that still remain, causing atrophy and de- 
generation of most of them, and thus reducing the size of the organ, which 
is followed by sclerosis. The portal and hepatic circulations are greatly 
obstructed. An occasional form is termed hypertrophic sclerosis 
in which sclerosis is found while the organ continues enlarged. 

There are two common and well defined varieties, atrophic cirrhosis 
and hypertrophic cirrhosis; other forms (rare) are met with. 

Atrophic cirrhosis is the common form, and is usually due to 
alcoholic excess. The surface of the Hver is rough and uneven in ad- 
dition to its hardness and reduction in size. It may also be greatly de- 
formed and covered with granulations ("hob-nails"). The normal 
weight is four or five pounds, but it may ])e so reduced as to weigh no more 
than one pound or a pound and one-half. Sometimes there is fatty in- 
filtration, which enlarges the liver to such an extent that the contraction 
is not noticed. There is an overgrowth of the connective tissue, which 
contracts and constricts the branches of the portal vein, causes atrophj^ 



The Practice of Osteopathy 561 

and degeneration of the hepatic cells, and even sometimes obliterates 
the bile ducts. The new connective tissue is well supplied with blood- 
vessels from the hepatic artery, thus aiding greatly in the growth. 

In the hypertrophic form, as well as in the atrophic cirrhosis, 
there is an overgrowth of connective tissue, but in the hypertrophic 
form the new form of tissue exhibits no disposition to contract. The 
enlargement of the organ is largely due to hyperemia. As the tissue 
does not contract there is no pressure on the portal vein and atrophj^ 
is prevented. There is early jaundice (which is a characteristic symptom) 
owing to obstruction of the biliary channels. The surface is smooth and 
its color is greenish yellow. 

Symptoms. — Atrophic Form. — There may be practically no symp- 
toms. As there is obstruction of the portal circulation, there may be con- 
gestion^ of the stomach and intestines, resulting in chronic gastric or 
intestinal catarrh having the following symptoms — anorexia, distress 
after eating, distention, constipation and coated tongue. Owing to 
the anastomotic communication between the portal and caval circulations, 
as the portal circulation becomes more obstructed, the superficial abdom- 
inal veins become greatly distended. Hemorrhoids occur, owing to the 
communication of the superior hemorrhoidal, which is a branch of the 
portal vein through the inferior middle hemorrhoids, with the hypogas- 
tric vein and the vena cava; hence hemorrhoids are a characteristic symp- 
tom. There is enlargement of the spleen and hemorrhage from the stom- 
ach or bowels. Edema of the legs and ascites are due to engorgement of 
the portal system. Ascites is much more common than edema of the 
legs. There may be sKght jaundice, although this is a rare symptom 
in atrophic cirrhosis. There is always decided emaciation. On examin- 
ation there is a diminished area of hepatic dullness, while the splenic 
dullness is enlarged. It is often impossible to outline these organs, as 
the abdominal distention prevents it. The urine is scanty, high-colored 
and often loaded with urates, but seldom bile-stained. 

In the hypertrophic form shght jaundice appears at the onset, 
which gradually deepens until it is intense and persistent. Occasion- 
ally there is fever. The disease as a rule is decidedly chronic, though 
acute symptoms may develop at any period. The urine is often bile- 
stained, but of normal quantity. On examination the liver is large, 
smooth and round and can be felt below the ribs. The spleen is greatly 
enlarged. 

Diagnosis. — In atropic cirrhosis. — With ascites without dropsy 



562 THi^ Practice of Osteopathy 

elsewhere, history of alcoholism, hemorrhage from stomach or bowels and 
reduction in size of liver, the diagnosis is absolute. 

Hypertrophic cirrhosis. — In cancer of the liver the patient is ad- 
vanced in years, has no splenic enlargement, and more commonlj^ ascites 
is present ; while in hj^pertropliic cirrhosis there is chronic biliarj^ obstruc- 
tion, the liver is only moderatel}'^ enlarged and hard, marked jaundice, 
with causes leading to or evidence of hepatic obstruction. This form of 
cirrhosis is also to be differentiated from amyloid liver and echinoccc- 
cus cyst. 

Prognosis. — Unfavorable, although in some cases the disease can 
be arrested during the early stage, provided the habits are regulated and 
treatment is continuous and persistent. Death usually occurs from one 
to two years after appearance of dropsy. Ascites is difficult to contend 
with. 

Treatment. — If the disease is recognized at the beginning and 
persistent treatment given to the liver, the chances are that atrophy of 
the cells and connective tissue formation will not take place. But or- 
dinarily cases of cirrhosis are incurable. The most that can be done is to 
reestabhsh a compensatory circulation in the liver. Otherwise it would 
be no more unreasonable to say that one could cure a chronic valvular 
lesion of the heart. The patient should live a quiet out-door life. Al- 
cohoHc drinking should be stopped. The diet should be Hght and nu- 
tritious, preferably a milk diet. The bowels should be kept open, the 
skin active and the kidneys closely watched. 

Fatty Liver 

In fatty infiltration there is no loss of function. The fat infiltrates 
the cell, crowding aside the protoplasm. This is largely a normal process, 
though fatty degeneration may be associated. 

In fatty degeneration the cell loses its structure and is changed into 
fatty tissue. Chronic intoxication from infectious diseases, such as 
phthisis puerperal fever, typhoid fever, pneumonia and syphilis are the 
principal causes. Alcoholism and phosphorous poisoning are other 
causes. 

Amyloid Liver 

There is infiltration into the tissues of the liver, of the socalled amy- 
loid substance. The infiltration begins in the blood-vessels, the hepatic 
artery first, then the central zone or periphery, and finall}^ all structures 
of the liver. This disorder should be viewed as a disturbance of meta- 
bolism. 



The Practice of Osteopathy 563 

Etiology and Pathology. — This condition is usually found in 
cases of prolonged suppuration, especially associated with tubercular 
disease of the bones as in hip-disease, syphihs, rickets, malaria, cancer and 
leukemia. It is beheved by some to be the result of microbic invasion, 
especially the tubercle bacillus and staphylococcus. Lesions are frequent- 
ly found from the fifth to the tenth dorsal vertebrae, which probably act 
as predisposing factors. 

The liver is considerably enlarged and rounded. It is pale or 
waxy in appearance and is doughy in consistency. On section it is anemic 
and whitish, partly due to infiltration into the walls of the blood-vessels 
narrowing the lumen. The amyloid changes may be circumscribed and 
in some cases fatty infiltration is present. 

Symptoms. — There are no characteristic symptoms except the 
enlargement of the liver, although the complexion may be waxy and there 
may be some gastro-intestinal disturbances. Pain is absent, although 
occasionally there is a dragging sensation, due to the weight of the organ. 
Jaundice is not present, but the stools may become Hght colored, owing 
to a diminished secretion of bile. The urine may be increased in amount 
and contain some albumin if amyloid occur in the kidneys. Emaciation 
and anemia are present and ascites seldom occurs. Amyloid changes 
involve the spleen, kidneys, intestines and other organs. 

Diagnosis. — The organ being large, hard and smooth, with absence 
of jaundice and ascites, the presence of albuminuria and an enlarged spleen 
and with the history of the case, mistakes are not hkely to be made. 

Prognosis. — Depends upon the cause. The progress may be rapid 
or slow. 

Treatment. — Careful attention to the primary disturbing factor 
and direct treatment to the Hver will, in some instances, reduce the size 
of the organ. Nitrogenous food and hygienic measures should be iij- 
stituted. The vasomotor nerves of the portal system (fifth to last dorsal) 
should be treated thoroughly. 

Gall-stones 

Gail-stones are concretions that originate in the gall-bladder and 
occasionally in the hepatic ducts. "The primary formation of gall- 
stones is itself largely dependent upon stagnation of bile, such as may 
aiise in the gall-bladder if an intermittent or incomplete closure of the 
cystic duct be brought about by such things as tight lacing, pregnancy, 
or even unequal sagging of the abdominal viscera. " — MacCallum. The 
stone is lai-gely composed of cholesterin, and may form without any 



364 The Practice of Osteopathy 

inflammation of the gall-bladder, owing probably to the stagnation 
affecting the bile salts so that the cholesterin is precipitated instead of 
being held in solution. 

More often there is inflammation of the wall of the gall-bladder due 
to microorganisms. This causes an exudate from which is derived the 
calcium. The calcium with bilirubin is deposited in layers on the stone 
which give it the various colors of yellow, brown or green. 

A rare type is one formed in the hepatic ducts, which is soft, green, 
and composed of calcium bilirubin concretions. 

The stones ''contain a great deal of organic material derived from 
desquamated epithelial cells and coagulated albuminous matter, as 
well as pigment." The colon bacilli, staphylococci, steptococci, typhoid 
bacilli, and pneumococci are the bacteria most frequently found. A 
cholecystitis may be a predisposing factor or it may be secondary to 
the concretion. 

Osteopathic Etiology and Pathology. — This is a disease of middle 
life and is more frequently found in women. Sedentary habits and 
constipation combined with overeating, are other important factors. 
It is found in stout subjects who are particularly fond of starchy and 
saccahrine food. Catarrhal jaundice is a predisposing factor. Depress- 
ing mental influences may predispose. The thicker the bile the more 
Hkely it is to deposit. Dr. Still's theory is that lesions of the ribs on the 
left side from the sixth to the tenth dorsal are factors in the formation 
of the stones as they interfere with pancreatic secretions. No matter 
how it comes about, the fact is that in all cases of gall-stones the osteo- 
path finds lesions to the eighth, ninth and tenth ribs on the left side, as 
well as lesions from the fifth or sixth to the tenth dorsal, deranging inner- 
vation to the liver and bile ducts. It is possible that lesions over the 
spleen probably interfere with the activities of the spleen and thus in 
some manner this organ does not properly elaborate the blood before it 
passes to the liver. Sagging of the duodenum may, through tension on 
the duodeno-hepatic ligament, interfere with the flow of bile. This 
would cause derangement of the nervous recipi'ocal relationship between 
opening at duodenal orifice and gall-bladder. In carcinoma of the liver 
and stomach, gall-stones are said to be frequent. 

The stone itself is a brownish object, nearly spherical, faceted and in 
some instances polygonal in shape, varying in size from a pea to a hen's 
egg. 

The stones are found anywhere in the biliary tract from the duo- 
denal orifice to the ramification of the bile vessels. Usually there is more 



The Practice of Osteopathy 565 

or less of an accumulation in tke gall-bladder At any point the stone may 
produce ulceration and suppuration. Perforation may occur into the 
peritoneal cavity or adjacent organs. 

Symptoms. — Gall-stones may be in the gall-bladder for years 
without giving rise to any symptoms. Their presence is made known 
onty by their expulsion from the gall-bladder. If they lodge in the duct 
in transit from the gall-bladder to the duodenum biliary colic is pro- 
duced, which is the characteristic symptom of an impacted gall-stone. 
Small stones may pass into the intestine without jDroducing symptoms. 
The pain is very sudden, piercing and excruciating in the region of the gall- 
bladder, when a stone attempts to pass. The pain radiates through 
the abdomen, right chest and shoulder, and the patient writhes in agony 
and occasionally faints. Downing^ emphasizes the point that when 
a patient comes in with a history of repeated attacks of biliary cohc and 
no stone found in the stools one should at once suspect that one of con- 
siderable size obstructs the common duct. 

There is always tenderness in the biliary region with more or less 
contraction of the abdominal muscles. Nausea, vomiting and sweating 
are usualty present, followed by a weak pulse, cool skin and pale and 
anxious face. Fever is soon present and a chill is common. The parox- 
.ysms continue as long as the stone remains lodged, which may be from 
an hour to several days. There are remissions of pain, entire relief being 
given as soon as the stone reaches the duodenum. Jaundice usually fol- 
lows a prolonged attack. The liver is sometimes enlarged. The spleen 
is enlarged. Should the stone become impacted, ulcerative perforation, 
with consequent peritonitis and shock, follows. 

Diagnosis. — The diagnosis is conclusive when the gall-stones are 
found in the stools or when they can be felt in the gall-bladder. All 
the above symptoms are characteristic. If a patient complains of severe 
pain radiating from the hepatic region, and nausea and vomiting are 
present, subsiding suddenly with a slight jaundice, the disease should 
hardly be mistaken. 

Tenderness over the gall-bladder frequently indicates infection or 
gall-stones or both. Radiographic examination may be of aid. 

Nephritic colic should never be confounded with hepatic colic 
as in the former the pains start in the lumbar region and radiate down- 
ward into the groin, the testicle and the inside of the thigh. In appen- 
dicitis, jaundice and bile-stained urine are not found. A pseudo- 
1. Journal of American Osteopathic Association, March, 1905. 



566 The Practice of Osteopathy 

biliary colic is occasionally found in nervous individuals especially 
when the eleventh and twelfth ribs (or ribs as high as the seventh) on 
the right side are displaced downward. 

Prognosis. — Is usually favorable. Ulceration, perforation, and 
suppuration may prove fatal, although much depends upon surgical 
interference. 

Treatment. — During the attack of biliary colic, the osteopath 
should usually be able to readily locate the position of the gall-stone in 
its transit from the gall-bladder. He should usualty proceed at once 
to aid the stone in its downward passage by careful manipulation over 
the duct. Still this treatment should be given with great caution, for 
if there is suppuration or ulceration, perforation and resultant periton- 
itis may occur. 

Usually one will not have much difficulty in dislodging the stone 
and relieving the sufferer in a few minutes. The recumbent position, 
with the thighs flexed on the abdomen, is the position assumed for treat- 
ment, and if the muscles in the hepatic region are very tense and rigid, 
interfering with locating the gall-stone, an inhibitory treatment to the 
posterior spinal nerves supplying the contracted muscles will aid one 
materially. An inhibitory treatment of the nerves of the biliary tract 
(the ninth and tenth dorsals), may be a helpful measure in dilating the 
duct. Also, hot appMcation over the affected area and to the dorso- 
lumbar region will aid. 

During remissions two or three treatments per week should be given 
to correct the lesions at the eighth, ninth, tenth and eleventh segments. 
Give particular attention to any enteroptosis that may be found. Av- 
erage cases should not require more than two or three months' treat- 
ment. Hildreth, who has had many cases, is much opposed to opera- 
tion as his experience has been that where there is not complete obstruc- 
tion the correction of lesions will prevent further formation of stones. 
While he finds the trouble ranges from the third to the eighth dorsal, 
still, as a rule," it is between the fifth and sixth that best results are ob- 
tained. Probably if the treatment is a rightly directed one the stones 
already formed may be disintegrated. Willard^ reports 393 cases. 

Permanently impacted gall-stones require surgical treatment. Pro- 
phylactic treatment, as a regulated diet, daily exercise and a discontin- 
uance of excesses, should be stronglj'^ urged. The patient should not be 
allowed any fatty or saccharine food. Water freely taken will be of aid. 

1. Journal of American Osteopathic Association, March, 1905. 



The Practice of Osteopathy 567 

Diseases of the Spleen 

Diseases of the spleen are usually secondary to other disorders. 
The following osteopathic treatment under Splenitis will, in addition 
to the probably primary disturbance, be appKcable to active and passive 
splenic hyperemia and amj^loid degeneration of the spleen. Surgical 
and other measures are to be employed when indicated. 

Owing to the role that the spleen plays in infections, the osteopath 
pays considerable attention to stimulating the organ through its spinal 
innervation in these cases. 

Splenitis 

In acute splenitis there is generally a blocking up of the smaller 
splenic arteries b}^ fibrous coagula (hemorrhagic infarct), which have 
formed in the left ventricle of the heart in consequence of endocarditis. 
Malarial infections, septicemia, typhus and acute exanthematous fevers 
may cause coagula formation in the splenic veins. Injuries to the ver- 
tebrae or ribs on the left side over the spleen (ninth to eleventh ribs inclu- 
sive) are occasionally the predisposing cause of primary inflammation of 
the spleen. Following the formation of abscesses the entire organ may 
suppurate; it may produce pyemia, or it may burst and the pus be dis- 
charged into the peritoneal sac, causing peritonitis, or into the pleura, 
stomach or colon. Chronic splenitis is induced by passive congestion, 
leukocythemia and splenic anemia. 

Symptoms. — Tenderness and enlargement of the spleen are the 
principal symptoms. The organ may be twice its normal size, but in 
a few cases the tumefaction is so insignificant that it can hardly be found 
on percussion. Dull pain generally exists if the enveloping membrane 
or adjacent organs are involved, the pain being increased upon percus- 
sion and deep inspiration. In a few cases the pain radiates to the left 
shoulder and if the peritoneal covering is involved, a sharp pain will be 
present. Fever and rigor follow if suppuration has taken place, and 
peritonitis follows in case of rupture or perforation. Marked hypertro- 
phy and chronic inflammation may cause cough, nausea, vomiting and 
dyspnea. 

Treatment. — In the treatment of both the disease producing 
splenitis, and of primary splenitis, a- thorough treatment of the spine, 
eighth to the eleventh dorsal, is necessar3^ The nerves (vasomotor) to 
the spleen are from the left splanchnics, consequently treatment of the 
left side is more effectual. Particular attention should be given the 
ribs over the spleen — the ninth, tenth and eleventh — as disorders of 



563 



The Practice of Osteopathy 



these ribs are a common cause of splenic disturbances. Careful and 
fairly firm treatment is always indicated, care being taken not to add 
irritation to an already inflamed organ, and especially beware that force 
is not used where there is danger of rupture. Stimulation of the tenth 
nerve contracts the spleen. In cases of suppurative splenitis the direct 
treatment should not be given. 

Stimulating treatment over the spleen, as over the liver and kidneys, 
gives tone to the strong elastic capsule surrounding it, so that direct man- 
ipulation over these organs, coupled with the power of the strong elastic 
capsule and highly elastic tissue of the inner organ, will greatly aid in 
lessening the engorgement and hyperemia. In a few cases where the 
spleen is involved, lesions are found in the upper cervical which affect 
the right pneumoeastric nerve and thus imoair the normal activity- of 
the gland. 



The Practice of Osteopathy 56P 

DISEASES OF THE RESPIRATORY SYSTEM 

DISEASES OF THE LARYNX^ 
Acute Catarrhal Laryngitis 

Definition. — An acute, catarrhal inflammation of the mucous 
membrane of the larynx. This may be ushered in as an independent 
disease or it may be associated with inflammation of the upper respira- 
tory passages. 

Osteopathic Etiology and Pathology. — One of the principal causes 
of acute catarrhal laryngitis is exposure to cold and dampness, which 
contracts the muscles of the neck region, especially about the larynx. 
Lesions in the upper and middle cervical vertebrae are important predis- 
posing causes. Occasionally the first rib becomes luxated, causing a 
greater or less congestion of the laryngeal mucous membrane by con- 
tracting the lower anterolateral muscles of the neck, and affecting Ij^m- 
phatic drainage. Improper placing of tone, as well as too constant use 
of the voice in speaking and singing, are common causes. Inhalation 
of irritating gases or dust, and mechanical injuries to the larynx are oc- 
casional causes. The disease may be associated with certain infectious 
diseases, as measles, diphtheria, influenza and whooping cough. 

Pathologically, the mucous membrane is intensely reddened and 
inflamed; this inflammation involves both the true and false vocal cords 
and may extend into the trachea and about the epiglottis. The mem- 
brane is covered slightly with mucous secretion. In rare instances edema 
of the glottis may occur. The muscular contraction about the larynx 
impedes blood and lymphatic drainage and thus induces congestion. 
The contraction may be so severe as to slightly prolapse the organ. The 
vertebral lesions impinge upon or affect vasomotor fibers and thus bring 
about congestion. 

Symptoms. — There is hoarseness and cough with a sensation 
of tickling in the larynx; these are the most constant symptoms. The 
cough is dry and the voice altered. At first the voice is husky, but some 
attempts at speaking are attended with more or less pain and finally 
the voice may be entirely lost. Deglutition is painful. At first the ex- 
pectoration is scanty, but later it becomes mucopurulent. There is 
rarely much fever. When there is considerable edema, dyspnea and 
asphyxia are prominent features. ■ 

1. I'or diseases of I hf nose see Deason, I'aii I, Pago 2r)7. 



570 The Practice of Osteopathy 

Prognosis. — Simple catarrhal laiyngitis never terminates fatally. 
When there is dyspnea or asphjocia indicating edema of the larynx, the 
prognosis is grave. The attack usually lasts from one week to ten days, 
but this can be materially shortened by careful osteopathic treatment 
In severe infections it may be two or three weeks before the larynx re- 
turns to its former condition. 

Treatment. — In a few cases confinement of the patient to his rooni^ 
and possibly the bed, will be necessary; especially should the larynx 
have rest from phonation, and the taking of food of an irritating char- 
acter should be avoided. Smoking is to be prohibited. The room should 
be at an even temperature, from 70 to 75 degrees F., and the atmosphere 
saturated with moisture by the generation of steam. 

The tissues in the cervical region about the cervical sympathetic 
and vagi nerves should be carefully adjusted. The deep posterior mus- 
cles of the cervical spine are to be relaxed and direct treatment given 
over and about the larynx. Relaxing tissues and raising the larynx will 
be very effectual in relieving the huskiness of the voice and in control- 
ling the congestion and inflammation of the laryngeal mucosa. Besides 
the treatment of the vagi nerves at the atlas and their course down the 
lateral and anterior portion of the neck, the superior laryngeal may be 
treated at the upper portion of the great cornu of the hyoid bone and the 
inferior laryngeal at the inner side of the cleido muscle near its sternal 
attachment. Adjust the tissues along the course of the external car- 
otid and subclavian arteries, chiefly the first rib ior the latter. Give 
careful treatment to the internal jugular and innominate veins. Cor- 
rect anj' tissues that may impinge upon the lymphatics of the mucous 
and submucous coats of the larynx where they are drained into the deep 
cervical glands. Release any immobility of the upper chest, relax the 
pectoral, auxiliary and upper dorsal muscles, and adjust the first four 
or five dorsal vertebrae. 

Prompt action of the skin, freedom of the bowels, placing the feet 
in a hot bath and continued local hot packs, or even an icebag in severe 
cases, will be of special value at the onset; but due attention should be 
given these throughout the entire course. The fever is easily aborted 
by the cervical treatment and proper attention to the bowels and sweat 
glands. 

Chronic Catarrhal Laryngitis 

Dehnition. — A chronic, catarrhal inflammation of the mucous 
membrane of the larvnx. 



The Practice of Osteopathy 571 

Osteopathic Etiology and Pathology. — The causes of chronic 
laryngitis may be numerous, but lesions of the cervical vertebrae are 
the most common. The contractured cervical muscles, especially the 
deep vertebral ones, are usualty the result of corresponding osseous de- 
viations. 

Other causes given under the acute form, as overuse and abuse of 
the voice, inhalation of irritating substances, excessive use of tobacco 
and alcoholic drinks, tumors, etc., are important etiological factors. 
Thus irritations inducing acute attacks, if repeated, will result in chronic 
catarrh. 

The pathological changes as revealed by the laryngoscope are 
swelKng of the mucous membrane, osccaional superficial erosions, and 
rarely ulceration. 

Symptoms. — The voice is usually hoarse and rough, being due to 
a thickening of the vocal organs. In severe cases the voice may be 
lost. There is fatigue and pain after slight use of the voice, a sense 
of tickling in the larynx which produces a desire to cough, and expector- 
ations of viscid mucus and mucopus. 

Prognosis. — The prognosis is sometimes unfavorable, although 
many cases are cured. 

Treatmient. — The patient must learn to ta.ke care of himself prop- 
erly. He should avoid overheated rooms and the use of tobacco and 
alcohol, and the throat should not be protected too much. It is a good 
plan to bathe the neck every morning and night with cold water. He 
should avoid loud speaking; the sound should be expelled by the abdom- 
inal muscles and diaphragm and not by the muscles of the throat. Ex- 
amine the upper air passages carefully for any obstructions and infections 
that might exist which are a source of irritation to the larynx. 

Special attention should be given to the atlas, axis and third cer- 
vical. Lesions lower down the spine may be found, for other laryngeal 
nerve fibers, other than those from the superior cervical ganglion, may be 
at fault. Palpate the hyold to see if it is tilted by contracted muscles, 
as will often be the case. 

Aphonia is commonly caused by a dislocated atlas. The aphonia 
may als(j Ijo caused by swelling of the vocal cords and tissues about them 
and by serous effusions of the laryngeal muscles. The larjmx may be 
prolapsed slightly and if raised quickly relieved. Difficult breathing and 
hoarseness are occasionally very troublesome symptoms. The former is 
due to an inabihty of the glottis to dilate, on account of swelUng of the 
mucous membrane of the diseased parts ;iimI from drying of the secretions 



572 The Practice of Osteopathy 

on them, thus increasing the obstruction (this is sometimes termed pseu- 
docroup) but expiration is easy, the stridor is from the inspiration; 
the latter is due to a collection of mucus on the vocal cords or the cords 
ma}^ become relaxed, swollen or roughened. 

Another annoying symptom sometimes presented is pain on de- 
glutition, which is due to swelhng of the mucous membrane of the upper 
larjmgeal passages and the epiglottis. In all of these annoying symp- 
toms, persistent, thorough, direct treatment of the larynx is of value. 
On the whole, careful, continued treament of the cervical innervation 
and vascular supply of the larynx, as in the acute form, is indicated. 

In all laryngeal disorders, if condition permits, hyperextend the neck 
while the patient is lying supine and thoroughly relax the soft tissues 
about the organ and then carefully raise it. 

Laryngismus Stridulus 

(Spasm of the Glottis) 

Definition. — A spasm of the muscles of the larynx that are sup- 
plied b}^ the inferior or recurrent laryngeal nerves. This is commonh' 
not excited by an inflammatory condition, but it is usually a purely ner- 
vous condition. 

Osteopathic Etiology and Pathology. — Spasm of the glottis is 
usually found in children with enlarged tonsils and adenoids. It 
has been observed that rickets and syphilis are probably frequent under- 
lying causes. The spasm is occasionally associated with tetany. The 
nervous factor is the immediate and important consideration. Cervical 
lesions, both vertebral and muscular, are invariably found. Then naso- 
pharyngeal and tracheal disorders and reflex digestive disturbance are 
exciting causes. An elongated u\n.ila or a deranged hyoid bone will oc- 
casionally be exciting factors. Subluxation of the upper two or three 
ribs and of the clavicle may also be exciting factors. 

The affection is usually found in children under five years of age. 
All cases are not of a distinct nervous type, for slight acute catarrhal 
laryngitis may be present. 

Symptoms. — There is a sudden onset and the spasm may occur 
on waking from sleep, but it may come on either in the night or day. 
The disease starts with a sudden arrest of breathing, the child sti'uggles 
for breath ; there are tonic muscular spasms and the face becomes congest- 
ed in a few seconds. This is followed by sudden relaxation of the spasm 
and the air is drawn through the glottis with a shrill, crowing sound. 



The Practice of Osteopathy 573 

Several spasms may occur in a day or they may be weeks apart. Death 
rarely occm^s. 

Diagnosis. — The absence of fever, cough and hoarseness and its 
distinctly intermittent nature will differentiate it from croup. Should 
there be any question of diagnosis a bacteriological examination is ad- 
visable. 

Prognosis. — The prognosis is almost always favorable. In very 
young children death from suffocation may occur, but rarely. 

Treatment. — The treatment should be applied either centrally or 
peripheral^, depending altogether upon the location of the irritation. 
If the irritation is of central origin, that is, through the innervation from 
the brain and spine, a correction of the superior and inferior laryngeal 
nerves is necessarj^; if the stridor is due to peripherial irritations, a cor- 
rection of the end-plates (muscles) over and about the larynx is required 
in order that the spasms be relieved. 

Thorough treatment should be applied to the upper part of the chest 
and diaphragm, chiefly the phrenic nerves at the third, fourth and fifth 
cervicals and over the eighth, ninth and tenth ribs anteriorly, in order 
that the spasms may be prevented from extending to the intercostal mus- 
cles and the diaphragm. 

Placing the patient in a hot bath will be of service in some cases 
when the spasms are severe. Alternating hot and cold packs about the 
throat are of service. The air of the room should always be kept moist. 
Care should be taken that the trouble is not due to gastro-intestinal dis- 
orders or to dentition. Keep the child upon a fluid diet of milk, meat 
broths and egg albumin. 

In the more severe cases the well known osteopathic method of re- 
laxing and inhibiting the soft palate and contiguous tissues will stop the 
spasm. 

Spasmodic Laryngitis 

(False Croup) 

Debnition. — A catarrhal inflammation of the mucous membrane 
of the laiynx with spasm of the glottis. 

Osteopathic Etiology and Pathology. — This affection is practic- 
ally the same as laryngismus stridulus associated with catarrhal inflam- 
mation of the mucous membrane. It is a disease of young children. 
Derangements of the innervation and blood supply to the laryngeal mu- 
cous membrane and muscles of the larynx are foimd in the same locality 
as noted under acute catarrhal laryngitis and laryngismus stridulus. 



574 The Practice of Osteopathy 

There is acute catarrh causing a croupy cough, and difficult breathing 
due to spasm of the glottis. 

Symptoms. — These attacks generally occur during the night, 
the child being suddenly awakened by severe paroxysms of suffocating 
and a dry, hard cough, associated with evidences of dyspnea. In half 
an hour or an hour or two the coughing ceases, perspiration follows and 
the child falls asleep. If proper treatment is not given, these attacks 
may occur for several successive nights, the child appearing almost or 
quite well during the day. 

Diagnosis. — The symptoms are so characteristic that the diagno- 
sis is easy. In all instances the prognosis is favorable. 

Treatment. — The catarrhal inflammation of the mucous mem- 
brane of the larynx should be treated in the same manner as simple in- 
flammation of the laryngeal mucosa, i. e., thorough treatment of the cer- 
vical spine and direct treatment over the larynx. 

During the paroxysm, if the patient cannot be relieved very shortly 
by the cervical treatment, he should be placed in a hot bath of a tempera- 
ture from 98 to 110 degrees F. This will, in the majority of cases, relieve 
the attack. In addition a hot compress may be placed about the throat. 
Producing emesis by irritating the fauces with the finger is necessary in 
a number of cases in order that the secretions in the laryngeal region may 
be ejected, thus relieving suffocation and labored breathing. Also, 
an overloaded stomach which is causing an irritation, should be emptied 
at once by vomiting. The bowels should be kept well open in all cases. 
Occasionally the epiglottis becomes wedged in the chink of the glottis. 
Such a condition requires an introduction of a finger into the fauces to 
release the disorder. 

Care should be taken, especially following an attack, that the child 
is not exposed to cold or rapid changes of temperature, so as to avoid 
repetition of the spasms. 

Coughing. — Coughing, not only in spasmodic laryngitis, but also 
in various diseases where coughing is a prominent symptom, is a most ir- 
ritating and annoying feature. The osteopath is many times called upon 
to relieve the cough, whether it is due to slight irritation of a nerve fiber 
alone or is a symptom of a serious chronic disease. The coughing center 
is located in the medulla oblongata; the afferent nerves are sensory branch- 
es of the vagus; the efferent nerve fibers are found in the nerves of expi- 
ration and in those that close the glottis. Consequently, coughing may 
be caused by stimuli to various sensory nerves, various cutaneous areas 
(chiefly the upper part of the body), mucous membrane of the respira- 



The Practice of Osteopathy 575 

tory and digestive tracts, the mammae, liver, spleen, ovaries, uterus, kid- 
neys, etc. Perhaps the most common cause of cough is contraction of 
some of the muscles of the neck, irritating sensory fibers. Contraction 
of the omo-hyoid muscle may produce an irritating cough by causing trac- 
tion on the hj'^oid bone. In a few cases the larynx may prolapse to some 
extent and thus be a source of irritation. Lesions of the spinal cord be- 
tween the seventh and eighth dorsal, also at various points above in the 
dorsal vertebrae and in the ribs (especially at the second and third ribs) , 
are very apt to produce a cough. Impaction of the sigmoid flexure is 
oftentimes accompanied by coughing. Enlargement of the heart may 
cause pressure upon the respiratory tract directly and cause a deep, dull 
cough. Foreign bodies in the external meatus of the ear are occasion- 
ally a source of irritation which is accompanied by coughing. Thus 
there are innumerable sources of stimuh that may produce coughing. 
In all cases it is nccessarj^ to make a careful diagnosis as to whether it 
is an irritation to some fiber that can be corrected at once or whether 
it is a symptom of a disease that, can only be relieved by the cure of the 
disease. In local congestions the cold pack will often be of service. 

Tuberculous Laryngitis 

Definition. — An inflammation of the larjmgeal tissues of tuber- 
culous origin. 

Osteopathic Etiology and Pathology. — Tuberculosis of the 
larynx is commonly secondary to pulmonary tuberculosis. In a few 
cases the laryngeal invasion may be of primary origin. In either in- 
stance there will be found a disturbed innervation or altered blood sup- 
ply of the larynx that predisposes to the multiplication and gi-owth of 
the bacilU. The osteopathic lesions are similar to those found in other 
involvements of the larynx. 

Pathologically, the mucous membrane is inflamed and swollen, 
and exhibits scattered tubercles, which are usually about the blood- 
vessels. The tubercles cluster, caseate and leave shallow, irregular ul- 
cers. There is thickening of the mucosa about the ulcer, and the ulcer 
is generally covered by a grayish exudate. The}^ may erode the true vo- 
cal cords, often destroying them completely. The ulcers slowly involve 
the tissues in all directions, causing perichondritis with necrosis of the 
cartilages. The mucous membrane of the pharynx, esophagus, fauces, 
and tonsils may be involved, and the epiglottis may be completely destroy- 
ed. 



576 The Practice of Osteopathy 

This disorder, strictly, should be discussed under pulmonary tuber- 
culosis for, as heretofore stated, it is generally a secondary affection; 
the larj^nx being invaded by the tubercular bacilli in the sputum arising 
from the bronchial tubes and lungs. The bacilli in inspired air may pri- 
marily invade the laryngeal mucosa. However, in either case the circu- 
lation of the mucosa is not normal and osteopathic correction of the same 
is effective. 

Symptoms. — Huskiness of the voice, followed by hoarseness, and 
in advanced stages aphonia, are prominent symptoms. A hacking 
cough is usually present and the patient complains of pain in the throat, 
particularly on coughing, swallowing or speaking. The loss of voice, 
painful speaking or whispering are quite characteristic. When the ul- 
ceration of the tissues of the larynx has progressed to a later stage, dys- 
phagia, suffocation and distressing paroxysms of cough occur. 

Diagnosis. — Is not difficult, as pulmonary phthisis is usually as- 
sociated with it. Examination of the sputum for the specific bacilli 
will he conclusive. 

Prognosis. — The prognosis is not of the best at any time. On the 
whole, it is unfavorable. 

Treatment. — In this disease osteopathic treatment has been quite 
effectual. Cases of primary origin are more successfully treated than 
when of secondary cause, although one will be surprised many times at 
the results obtained when the disorder is not primary. The treatment 
must necessarily be both constitutional and local. Care of the general 
health as to hygiene and diet is absolutely necessary. The food must 
be nutritious and non-irritating. Scraped beef, raw oysters, raw eggs, 
soups and gruel are required. In cases where difficult}^ of deglutition 
occurs, it ma}'^ be largely overcome if the patient hangs his head over the 
side of the bed and sucks through a tube liquid nourishment placed n 
a dish upon the floor. 

The local treatment required is careful, persistent work over the lar- 
ynx and adjacent tissues. The treatment is given to increase the blood 
supply to the diseased tissues so that healing may take place, and that 
the bacteria may be deprived of the conditions favorable to their activity. 
Treatment along the cervical spine and upper dorsal will aid in cor- 
recting the vasomotor disorders that exist. Local apphcation of hot wa- 
ter will assist in relieving the pain. When pulmonary phthisis exists, 
attention and correction of it is important; in fact, is of primary consid- 
eration in laryngeal affection. 



The Practice of Osteopathy 577 

Syphilitic Laryngitis 

Etiology. — This disease is of frequent occurrence, due to inherited 
syphiKs, or to the secondary or tertiary stages of the acquired form. 

Symptoms. — There is a hoarseness of the voice, a hacking cough, 
difficulty in swallowing and the various symptoms of catarrhal laryngitis. 
The secondary form may present superficial, whitish ulcers on the cords 
or ventricular bands, while in a tertiary stage the lesions are extensive 
and serious. Deep ulcers with raised edges are present, gummata devel- 
op on the submucous coat of the epiglottis and there may be necrosis 
and exfoliation of the cartilages. Deformity is produced by the cica- 
trices following the heaHng of the ulcers and sclerosis of the gummata. 
Edema of the larynx may suddenly prove fatal. 

Diagnosis. — The history of the case, the presence of other symptoms 
of the disease, the deep, symmetrical ulcers, the absence of tuberculosis 
elsewhere and the absence of marked pain, will usually make a diag- 
nosis easy. 

Prognosis. — Is somewhat favorable, more so at least than the 
tubercular form of laryngitis. There is great danger of deformity and 
permanent impairment of the voice. 

Treatment. — The treatment should be both constitutional and lo- 
cal. Active measures must be taken to rid the system of the virus of 
syphiHs, and thorough, direct treatment should be applied to the larynx 
and to its innervation. If the cicatricial stenosis has progressed so far 
that there is Httle hope from manipulative treatment, tracheotomy or 
gradual dilatation should be performed. The ulcerated portion is always 
to be kept clean. 

Edematous Laryngitis 

Definition. — An acute inflammation of the mucous membrane 
of the larynx with infiltration of serous fluid into the submucous tissue. 

Etiology.— This is a verj^ serious affection. It may occur in con- 
nection with acute laryngitis, though rarely, and occasionallj^ with chron- 
ic diseases of the larynx, as tuberculosis and syphihs. It may be a com- 
plication of some acute infectious disease like diphtheria, scarlet fever, 
or erysipelas of the face. It sometimes occurs suddenly in the course of 
Blight's disease. Lesions as in acute laryngitis are predisposing factors. 

Pathologically, there is marked sweUing of the epiglottis. The 
swelling can very easily be felt with the fingers. The mucous membrane 
is tense and changed in color. There is infiltration of a serous or sero- 



578 The Practice of Osteopathy 

purulent fluid into the loose connective tissue of the larynx. The ary- 
tenoepiglottic folds are greatly involved, and they may be swollen to 
such a degree that they almost meet. 

Symptoms. — Extreme dyspnea and stridulous respiration. Hoarse- 
ness of the voice and later aphonia. There is a feehng of intense oppres- 
sion or suffocation. Evidence of dyspnea, anxious face, blue hps, pro- 
truding eyes and retraction of the base of the chest occvn\ The sterno- 
cleido-mastoid muscle is very prominent. 

Diagnosis. — This is not difficult. The history of the case, laryn- 
goscopic examination, and the swollen epiglottis which can be easily 
felt with the fingers make diagnosis easy. 

Prognosis. — Generally unfavorable. At any time it is extremely 
grave, but with prompt and vigorous treatment recovery is possible. 

The duration varies from a few hours to several days. 

Treatment. — One must attend strictly and carefully to the lar}^- 
geal innervation, as in acute catarrhal laryngitis. Obstruction to the 
superior or inferior thyroid, facial, internal jugular or innominata will 
cause tumefaction and edema of the larynx and adjacent tissues. Also, 
enlargement of the lymphatics about the larynx and salivary glands may 
produce edema of the laryngeal region; consequently, particular care 
should be taken of the various tissues about these vessels and of the in- 
nervation from the cervical spine, so the veins are not obstructed or the 
Ijmiphatic channels disordered, so that infiltration of the tissues may 
be further prevented. 

The most prominent symptom is laryngeal dyspnea and this de- 
pends altogether upon the swelHng of the soft parts. If the swelling 
is great and the disorder cannot be removed, suffocation will follow. 
In such cases, besides giving direct treatment over the larynx, introduc- 
ing a finger into the mouth, and reaching clear back under the roof of the 
soft palate, with a firm, downward, outward and sweeping movement 
on either side, relax the soft tissues. The persistent use of small pellets 
of ice, held far back in the mouth, will be found very beneficial; also, ap- 
plication of the ice-bag, provided the edema is of inflammatory origin. 

If one is not able to control the rapid infiltration of the larynx and 
glottis when such cases arise, tracheotomy or intubation should be per- 
formed at once. When edematous laryngitis is due to diseases of the 
heart, lungs and kidneys, treatment of the primary disease should be 
given in addition to the local treatment. 



The Practice of Osteopathy 579 

DISEASES OF THE BRONCHI 
Acute Bronchitis 

Definition. — A catarrhal inflammation of part or whole of the 
mucous membrane of the larynx, trachea and bronchial tubes, or it may 
extend into the capillary tubes. This is bilateral, affecting more or less 
the bronchial tree in both lungs. 

Osteopathic Etiology and Pathology. — The most common cause 
of acute bronchitis is ''catching cold." It is more prevalent in the 
winter, and it often succeeds an ordinary cold in the head, coryza or laryn- 
gitis, the inflammation extending downward from the upper air passages. 
A case of acute bronchitis always presents a contracted condition of the 
muscles on either side of the spine in the upper dorsal region. The 
contracted muscles may extend as far down as the middle dorsal or as 
high as the entire cervical. Occasionally, the ribs posteriorly are drawn 
downward by the extreme contraction of the muscles, and the upper an- 
terior part of the chest may be somewhat constricted and hmited in its 
movements by the tensed muscles. Thus, in a few cases the ribs and up- 
per dorsal vertebrae are actually sub-dislocated by the extreme con- 
traction of the muscles. The principal points affected are the second, 
third, fourth and fifth dorsal regions. In a few instances cervical lesions 
disturbing the vagus and resulting in motor weakness of the tubes, will 
be noted. The osteopathic control of the bronchial vasomotor nerves 
is in this region (dorsal). 

The disease is also associated with measles and it is usually a symp- 
tom of influenza. One attack predisposes to another. It affects either 
sex and especially children and the old, in whom it most frequently in- 
volves the smaller bronchi. In adult life it involves the larger bronchi. 
Micro-organisms, particularly the pneumococcus, influenza bacillus, and 
micrococcus catarrhalis, act as exciting causes. 

Pathologically, the mucous membrane of the portion of the tra- 
chea and bronchi tha.t are impHcated become reddened, congested and 
more or less covered with a tough mucus mingled with epithelial cells. 
The hyperemia is most marked about the mucous glands. Some of 
the smaller bronchial tubes are dilated. In severe cases there is desqua- 
mation of the ciliated epithelium, swelling and edema of the sub-mucosa, 
and infiltration of the tissues with leucocytes. The affection involves 
cliiefly the vasomotor nerves. In cases on the verge of chronicity, look 
well to the diet; especially lessen in amount the starchy and saccharine 
foods. 



580 The Practice of Osteopathy 

Symptoms.— The onset of acute bi'onchitis is accompanied by 
the symptoms of a common "cold." In the beginning the cough is hard 
and dry without expectoration; but later it is looser, the secretion becom- 
ing mucopurulent and abundant and finally purulent. The scanty 
sputum is at first glairy and mucoid, while later it becomes more abund- 
ant and mucopurulent and contains pus-cells and desquamated epi- 
thelium. When the bronchial inflammation becomes fully estabhshed, 
there is a feeling of tightness and rawness beneath the sternum and a sen- 
sation of oppression in the chest, due to swelhng of the mucous mem- 
brane and the presence of secretions which cause stenosis of the bronchial 
lumina. There is a sHght fever, rarely exceeding 101 degrees F. The 
disease lasts from four or five days to three weeks. There is either a com- 
plete recoveiy or chronic bronchitis is developed. 

Physical Signs. — There may be no physical signs in shght attacks 
of acute lironchitis of the larger tubes. In severer cases the physical 
signs are well marked. Inspection maj^ recognize increased frequency 
of breathing, and M^hen the smaller tubes are involved there is dyspnea. 
Palpation. — The bronchial fremitus may often be felt, providing there 
is sufficient narrowing of the breathing tubes. Percussion. — Sounds 
are normal as long as the bronchitis is uncomplicated. Auscultation. — 
In the early stage piping, sibilant rales ma}^ be heard on both sides. These 
rales are inconstant and appear and disappear with coughing. There 
may be harshness of breathing added to these. When resolution sets 
in, the rales change and become mucous and bubbling in quahty. Vo- 
cal resonance in bronchitis is normal, unless complications occur. 

Diagnosis. — This is generally easy. The absence of dullness and 
blowing breathing and the bronchial character of the cough and expec- 
toration are usually sufficient to distinguish it from pneumonia and 
pleurisy. If the physical signs are noticed carefulty, the diagnosis is 
rendered easy and positive in all cases. 

Prognosis. — In the very young and the very old, the prognosis is 
unfavorable, but in a previously healthy adult the most that can hap- 
pen to a case of acute bronchitis is to become chronic. Recovery is the 
rule; even in the aged and feeble death is rare. If osteopathic treatment 
can be instituted from the inception, the disease will probabl}" be aborted. 
The treatment almost invariably lessens the severity and duration of an 
attack. For capillary bronchitis see Bronchopneumonia. 

Treatment. — Complete rest in a warm bed, and a hot foot bath 
would cure a large majority of cases in a day or two if the patient would 
only submit to such treatment. Most of them wish to be around and 



The Practice of Osteopathy 581 

out doors and very likely attending to their usual work, so that a cure in 
some cases is hard to perform. They are very liable to take more "cold" 
and in a few cases it will take great effort to prevent the bronchitis from 
becoming chronic. One thorough treatment per day will usually be 
sufficient. 

The hj^peremic condition of the bronchial tubes is due to a vaso- 
motor disturbance, generally caused by a severe contraction of the mus- 
cles of the back in the region of the first to fom^th dorsal; although the 
vasomotor nerves to the mucous membrane of the bronchial tubes may 
be affected anywhere from the first to the seventh dorsal inclusive. Con- 
traction of the muscles over the anterior part of the chest corresponding 
to these regions and caused by the same influences (chiefly atmospherical 
changes) is of quite common occurrence. In the majority of cases the 
contraction of the chest and back muscles is so severe that the ribs are 
partly displaced by the tension and thus is added a complication to the 
disorder, and from this complication chronic bronchitis is liable to occur. 
The ribs or even vertebrae to the corresponding region oftentimes remain 
partly dislocated and are a source of continued and permanent irritation 
to the innervation of the bronchial tubes. So it is always necessarj^ in 
treating any form of bronchitis to see at each treatment that the ribs 
and vertebrae from the first dorsal to the seventh dorsal, inclusive, are 
anatomically correct. 

As has been stated, the disordered muscles or ribs may be affected 
anteriorly as well as posteriorly; consequently, the treatment applied 
is a thorough relaxation of the chest and back muscles and the correction 
of the ribs and vertebrae in order that the vasomotor disturbance of 
the bronchial mucosa may be corrected and the inflammation relieved. 
An excellent method to release the immobifized anterior upper chest is 
to place patient flat upon his back with pillow beneath upper dorsal. 
This hyperextends spine, enlarges spinal foramina, and tends to elevate 
ribs. Then by use of arms as levers, moderate inspiration, and em- 
ployment of one hand over anterior end of ribs they may be easily re- 
leased and raised. This treatment effects circulation, innervation, lymph 
tissue, and rib bone marrow. 

In addition to the dorsal spinal nerves, and the sympathetic, the 
vagi are to be considered in the treatment of bronchitis, as all of these 
nerves, s^Tnpathetic, spinal, and vagi, go to make up the anterior and 
posterior pulmonarj^ plexuses from which the bronchial mucosa receives 
its innervation. The veins particularly involved in passive hyperemia 
of the bronchial tubes are the superior intercostal and azygos major; 



582 The Practice of Osteopathy 

so raise and spread the ribs to give greater freedom to these bloodvessels. 

"The blood flow may be diverted from the bronchi to the abdomen 
by a slow, deep, inhibitive treatment over it, including pressure over the 
solar and hypogastric plexuses. " (Hazzard). 

The excretory organs and the diet of the patient should be attended 
to. Especially in children, the diet had best be a fluid one, as milk, egg 
albumin, meat broths and meat juice. For those who are subject to 
the disease an outdoor life is best. 

Chronic Bronchitis 

Definition. — A chronic inflammation of the mucous membrane of 
the large and middle sized bronchial tubes. 

Osteopathic Etiology and Pathology. — Chronic bronchitis may 
be either primary or secondary. The primary form is the result of expos- 
sure to wet and cold or to the daily inhalation of irritating vapors or dust. 
This form is rare, the affection being almost always a secondarj^ one, and 
is most commonly met with in chronic lung affections, heart disease, 
gout or renal disease. It ma}^ be caused by any disease which favors 
congestion of the air tubes by obstruction of the circulation; especially 
mitral diseases and Bright's disease. It is also caused by chronic al- 
coholism and may be the result of repeated attacks of the acute form. 
Chronic vertebral and rib lesions are found from the first to the seventh 
dorsal, inclusive. Elderly people are often subject to the disorder. 

Pathologically, the lesions of chronic bronchitis present great 
variation, as to both their nature and extent. In some cases the mucous 
membrane is atrophied, so that some of the elastic fibers are noticeable. 
The epithelial layer is in great part missing. The muscular coat and mu- 
cous glands are atrophied. 

In certain cases the mucous membrane of the bronchi is thickened, 
and there may be ulceration. In long standing bronchitis, there is 
frequently dilation of the tubes (bronchiectasis) and emphysema. 

Symptoms. — Pain is rarely present; there is merely a feeling of 
constriction lieneath the sternum. The cough varies with the weather 
and season and there is often an absence of the cough during the summer. 
It is apt to be worse at night than in the morning, and is frequently par- 
oxysmal. There is rarely any fever. As a rule, there is free expector- 
ation of mucopurulent or distinctly purulent matter. Sometimes it 
is abundant, seromucous in character, and again there are severe cases 
of dry cough in which there is almost no expectoration. Unless asso- 



The Practice of Osteopathy 583 

ciated with other diseases, the general health suffers but httle, if at all. 
The appetite, as a rule, is good and the body weight is well maintained. 

Physical Signs — Inspection.— There is considerable immobihty 
of the chest and if emphysema is present there is distension. Percussion 
is clear, and hyperresonant in emphysema. Auscultation. — The ex- 
piration is prolonged and forcible. This is associated with sonorous 
and sibilant rales and moist rales of all sizes. 

Special Varieties. — Bronchorrhea, dry catarrh, putrid bronchi- 
tis or fetid bronchitis. 

Bronchorrhea. — In this form there may be an excessive bron- 
chial secretion. This may be liquid and watery, but more frequently 
it is purulent, thin and containing greenish masses; or again it may be 
thick. Dilation of the tubes and fetid bronchitis may be developed. 

Fetid Bronchitis. — Fetid expectoration is associated with gan- 
grene of the lungs, abscesses, bronchiestasis, decomposition of matter 
within phthisical cavities, or empyema with perforation of the lungs; 
or it may occur independently. There is considerable expectoration 
that is thin and offensive. When putrefactive changes take place dur- 
ing the course of chronic bronchitis, as a rule, the following symptoms 
immediately appear: fever, which may be septic; increase of cough; pain 
in the side, and sometimes a chill. There is increased prostration. 
The symptoms may abate followed by the usual course of bronchitis. 

Dry Catarrh. — The cough is distressing and paroxysmal. It is 
usually associated with emphysema and is a very troublesome form. 

Diagnosis. — This is not usually difficult. Phthisis — the absence 
of fever, of hemorrhage, of tubercle bacillus and the signs of locaUzed 
consolidation (usually at one or other apex) will serve to distinguish be- 
tween the two. 

Prognosis. — Recovery is not always accompHshed. The diseases 
being generally a secondary affection, the prognosis must depend upon 
the primary condition. The danger from development of emphysema, 
bronchiectasis and dilatation of the right ventricle must be thought of. 
Frequently cures will be obtained, even in old persons. Care must be 
taken that there are no serious organic lesions. Deep treatment to re- 
adjust the upper and middle dorsals is most essential. 

Treatment. — In the first place there must be a careful regulation 
of the hygiene of the patient. The diet should be a nutritious one, care 
iK'ing taken to give food that is easily digested. A liberal diet can easily 
he selected from the various meats, vegetables, cereals, fruits, soups, 
l)roths, eggs and milk. The clothing should be carefully selected. Flan- 



584 The Practice of Osteopathy 

nel should be worn next the skin the year around, care being taken that 
the sufferer is not too warmly clad. Due attention should be given to 
bathing, exercising, etc. The patient should be out in the open air a 
great deal, but be careful that it is not too stormy. The air of the room 
should be kept at an even temperature and not subject to abrupt changes. 
Two or three treatments per week will be required, and when the condi- 
tion is considerably aggravated, do not hesitate to treat oftener, but be 
careful not to unduly irritate the lesions. 

Lesions will be found to the ribs and vertebrae from the first to 
the seventh dorsal inclusive. Many cases present lesions in the verte- 
brae from the second to fourth, usually of a lateral nature. Other lesions 
of frequent occurrence are displacements of both vertebrae and ribs. 
Correcting these deviations reheves the chronic inflammation of the tubes. 
Also in those cases where dilatation of the bronchial tubes occurs, the 
obstruction to the motor fibers is to be removed by the correction of the 
vertebrae and by removing obstruction to fibers of the pneumogastric ; the 
fibers of the latter supplying the transverse muscles of the bronchial tubes. 

It generally requires a considerable course of treatment for the 
cure of chronic bronchitis, and one of the hardest things to contend with 
in the treatment is the hkehhood of the patient " catching cold. " When 
a fresh cold gets thoroughly started, it is almost impossible to prevent the 
disease from extending down the bronchial tubes, as the innervation is less 
rich in the smaller tubes. 

Hazzard says: "The obese should be taught the habit of deep res- 
piration, as should all persons subject to the attacks of the disease. This 
measure, together with the daily cold sponge or shower bath, is a great 
aid in overcoming the chronic tendency. " 

Those cases that are due to cardiac or nephritic diseases require the 
treatment of the primary disease in addition to a light bronchial treat- 
ment. 

A lesion between the gladiolus and manubrium of the sternum may 
be found, but it is of rare occurrence in these cases. The upper portion 
of the sternum may be held verj^ rigidly and slightly underneath the 
middle portion of the sternum; or at the point of articulation of the two 
portions a distinct ridge may be found, caused by the articular ends be- 
ing pushed antei'iorly. Probably such lesions affect the innervation to 
the bronchial tubes and lung tissues. Associated with this condition the 
upper chest is considerably immobilized, affecting the lymph and rib 
bone marrow function. Examine the first ribs and clavicles carefully. 
Changes of climate are often beneficial. 



The Practice of Osteopathy 585 



Fibrinous Broncliitis 



Definition. — A rare, acute or chronic inflammatory disease of the 
bronchi, in which a fibrinous mould of the bronchus and its branches is 
formed. These are expelled in paroxysms of cough and dyspnea. The 
casts block the bronchial tubes. When these moulds are large or medi- 
um sized, they are generally hollow, while those of the smaller bronchi 
are solid. 

Etiology and Pathology. — The causes are unknown. Young 
men, between the twentieth and fortieth years, are the usual subjects; 
but the disease may occur at any period of life. Lesions occur as in other 
forms of bronchitis. The attack occurs most frequently in the spring 
months. In some cases there seems to be some hereditary influence. 
Chronic pulmonary diseases, like phthisis, emphysema and pleurisy, are 
occasionally predisposing causes. It is sometimes associated with skin 
diseases, such as herpes, impetigo and pemphigus. 

The pathology is not known. The masses that are expelled are usu- 
ally round and mixed with blood and mucus. The casts are more dense, 
but the membrane is identical with that of croupous exudates. This 
affection, however, is limited to certain bronchial tubes and recurs at 
stated or irregular intervals, sometimes for a period of several years. 
There is loss of epithelium in the affected bronchi and the submucous 
tissue is often swollen and infiltrated with serum. 

Symptoms. — Acute cases are rare. The attacks may set in with 
rigor, high fever, pain in the side, soreness, severe paroxysms of cough 
and sometimes a sHght hemoptysis. The symptoms are those of an or- 
dinary acute bronchitis, but of severer character; aggravated cough and 
dyspnea and fatal termination are not uncommon. Death occassional- 
ly results from suffocation. There may be but one attack without any 
recm-rence, but in the chronic form the paroxysms recur at irregular in- 
tervals, though they are less severe than in the acute form. 

The disease may last for ten or even twenty years, the attacks re- 
curring weekl}^, or a period of a year or more may intervene. The on- 
set is marked by bronchial symptoms with or without fever. The cough 
soon becomes distressing and paroxysmal in character. The sputum may 
be blood-stained and occasionally there is profuse hemorrhage. The 
expectoration is in the form of ball-like masses which, when unraveled 
arc found to be moulds of the bronchi. They may be hollow and laminat- 
ed or quite solid. When examined under the microscope they are seen 
to consist of a fibrillatod membrane in which are imbedded leucocytes, 



586 The Practice of Osteopathy 

mucus, corpuscles, fat drops and epithelial cells. Leyden's crystals and 
Curschmann's spirals are occasional!}^ found. 

Physical signs are usually those of broncliitis. The weakened or 
suppressed breath sounds in the affected territory may occasionally be 
determined. There is sometimes a diminished expansion or even retrac- 
tion of the chest wall over the affected area. There is no dullness on per- 
cussion, unless the portions of the lung suppHed by the affected tubes 
collapse. After dislodgement of the casts, the normal respiratory murmur 
returns. 

Diagnosis. — The fibrinous casts alone are sufficient for a positive 
diagnosis. 

Prognosis. — Generally favorable. In uncomplicated cases there 
is rarely any danger, even though there may be severe paroxysms of cough 
and dyspnea. In fatal cases the lesions of associated or preceding affec- 
tions have been found, such as chronic pleurisy, pneumonia and phthisis. 
Although this is a rare disease, cases have been treated with success by 
osteopathic means. If uncompUcated there should be a fair chance for 
a cure, depending, of course, upon the constitutional condition and the 
permanency of the lesions. 

Treatment. — The treatment is largely that of acute bronchitis. 
The disorder is more extensive than in acute broncliitis, consequently 
severe subluxations of the ribs and vertebrae of the upper and middle 
dorsals occur, besides extensive muscular contractions of the chest and 
neck. The fibrinous casts are somewhat of the same nature of mem- 
branous exudates elsewhere, therefore the treatment shguld be directed 
to a correction of the hyperemia of the mucous membrane of the bron- 
chial tubes, thus loosening and disorganizing the exudate. The vagi 
nerves supply a part of the innervation to the bronchial tubes and lungs. 
Any disorder to them should be corrected when diseases of the bronchial 
tubes and lungs exist. They contain motor fibers to these organs, and 
to the bronchial tubes they supply, principally the transverse fibers. 
In bronchitis of various forms, marked effect can be secured by close 
attention and treatment to the inferior laryngeal nerve. This is best 
treated at the inner side of the lower portion of the sterno-cleido muscle. 

The different forms of bronchitis illustrate the point so often noted 
in osteopathic etiology and pathology, that the various affections of the 
same region should not be studied so much as types of several diseases 
or disease entities as different degrees of involvement, depending on the 
severity of the causative lesion, the function of the nerves disturbed, 
and the character of the tissues. It is straining a point to diagnose and 



The Practice of Osteopathy 587 

classify many diseases according to signs and symptoms instead of study- 
ing the process from central causes, for, at best, peripheral manifesta- 
tions, micro-organisms, etc., are really incidental to the importance of 
the primary source of disturbed nutrition. Consequently, the same 
treatment, if scientific, is frequently indicated for all of the disorders 
that may affect a given locality. After all has been said and done, the 
therapy as well as the pathology, must hinge upon the fundamental — 
uninterrupted blood channels and nerve courses are essential to health. 
Whether a disease is of primary or secondary origin, or whether or not 
it presents different symptoms in various types, the above basic princi- 
ple is invariably appHcable. This simplifies etiology, pathology and 
treatment and furnishes a backbone to theory and practice, and some 
day rational medicine will adopt it. 

Bronchiectasis. 

Bronchiectasis is a dilatation of a part or the whole of the bron- 
chial tube. As a rule this affection is a secondary one, the most common 
cause being chronic bronchitis. The inflammation weakens the broncliial 
walls so that they are unable to resist the strain that is put upon them 
during violent paroxysms of coughing. After dilatation has once com- 
menced, the weight of the secretion which accumulates tends to further 
distend the weakened walls and the elasticity, becoming impaired, is 
finally lost. Dilatation of the bronchi is also associated with emphysema, 
compression of a bronchus, aneurism or mediastinal tumor, broncho- 
pneumonia, measles and whooping cough in children, and also traction 
associated with fibroid induration. Hence the bronchial dilatation is 
especially associated with bronchitis, interstitial pneumonia, and some- 
times chronic pleurisy. It is rarely a congenital effect in such cases. It 
is commonly unilateral. The lesions presented to the osteopath are 
largel}^ Hke those found in chronic bronchitis, i. e., derangement of the 
upper four or five dorsal vertebrae and ribs, and lesions of the cervical 
vertebrae involving the vagi. These lesions obstruct the nerve force to 
the bronchial tubes and thus cause the dilatation. 

Pathologically, the dilatation is usually either cylindrical or sac- 
cular, which may occur in the same lung. The entire bronchial tree 
may be converted into a series of sacs opening into each other. These 
have smooth, shining walls in the most dependent parts which are some- 
times ulcerated. In extreme conditions the dilatations may form large 
cysts immediately beneath the pleura; as a rule, the lung tissue lying 
between the sacculi becomes cirrhotic. Partial dilatation is more 



588 The Practice of Osteopathy 

common. The bronchial mucous membrane is involved with an oc- 
casional narrowing of the lumen. The narrowings are most commonlj^ 
cyhndrical, sometimes saccular. 

In all forms there is decided change in the bronchial wall. In the 
large dilatations, the epithelium is changed. The elastic and muscular 
la3^ers are thin and atrophied. These dilatations frequently contain 
fetid secretions and when these secretions are retained, the hning mem- 
brane becomes ulcerated. 

Symptoms. — There is always cough, which occurs in severe par- 
oxysms. In some cases a change of position will cause a paroxysm of 
coughing — very likely due to the emptying of the contents of a dilated 
tube into a normal one. The sputum is mucopurulent and is greenish 
brown in color, is fluid, and has a sour, or more frequently, a fetid odor. 
On standing, it separates into three layers; the upper is frothy and thin, 
the middle mucoid, and the lower is a thick sediment of cells and granu- 
lar debris. Microscopically, the sediment consists of pus corpuscles, 
fatty acid crystals which are arranged in the form of bundles, and some- 
times red blood discs and hematoidin crystals. Elastic fibers may be 
found if ulcers are present. 

Physical Signs. — When distinctly present, thej^ are those of a 
cavity in the lungs. When chronic pleurisy and interstitial pneumonia 
are associated, there may be retraction of the chest wall. The percus- 
sion resonance is impaired. On auscultation, bronchial, or even am- 
phoric, breathing is heard occasionally with metallic rales. 

Diagnosis. — In a number of cases this was formerly impossible, 
where the X-ra}^ is now proving of great assistance. History, paroxysmal 
cough, characteristic copious sputum and an absence of tubercle bacilli 
with little impairment of the general health will serve to distinguish 
bronchiectasis from pulmonary tuberculosis. Circumscribed empyema 
which has ruptured into the lung may simulate bronchiectasis. This 
is of a much more sudden onset, has a history of previous pleurisy, the 
health is gradually impaired, and there is thoracic oppression and dysp- 
nea on the slightest exertion. 

Prognosis. — Is generally unfavorable. However this largely de- 
pends upon the cause. 

Treatment. — Largely the same as in chronic bronchitis. Severe 
lesions are found in the dorsal vertebrae about the region of the third, 
fourth and fifth, and many times lesions of the . pneumogastric at the 
upper cervical vertebrce are also found. The lesions are much of the 
same nature as those of bronchitis, but, as a rule, there is a much deeper 



The Practice of Osteopathy 589 

or more extensive lesion. These lesions weaken the motor innervation 
to the muscular coats of the bronchial tubes, and in many instances the 
extensive lesions involve the vasomotor nerves controlUng the blood 
supply to the bronchial tubes. In most cases marked lesions of the ribs 
on either side will be found, usually in the region corresponding to the 
affected vertebrae. 

The position of the patient is important; the head should be low in 
sleeping. In certain fetid cases surgery should be considered. 

Care should be taken as to the hygienic surroundings of the patient. 
The diet should be carefully regulated and nutritious, as in chronic bron- 
chitis. 

Bronchial Asthma 

Bronchial or spasmodic asthma is a chronic affection, charac- 
terized by a paroxysmal dyspnea due to a spasmodic contraction of the 
muscles of the bronchial tubes or to swelUng of their mucous membrane. 

Osteopathic Etiology and Pathology. — The majority of lesions 
causing bronchial asthma are from the second to the seventh dorsal 
region, inclusive, either in the ribs posteriorly or anteriorly, or in the 
vertebrae. These lesions involve vasomotor nerves to the bronchioles 
which produce the narrowing of the tubes and thus cause the dyspnea. 
Usually the lesion is at the third, fourth or fifth rib on the right side, 
although, as stated, a lesion may be found above or below this point at 
the anterior or posterior ends of the ribs or in the vertebrae corresponding 
to the same region. Probably lesions are found more on the right side, 
because most people are right handed; these muscles being better devel- 
oped would tend, when contracted, to draw the ribs from their articula- 
tion. The third, fourth and fifth ribs are usually found involved because 
it is the region of greatest vasomotor innervation to the bronchial tubes 

In a number of cases there will be found a posteiior curvature of 
the dorso-lumbar region; and accompanying this condition will be ca- 
tarrh and dilatation of the stomach, congestion of the liver, and, perhaps, 
intestinal indigestion and constipation. Careful attention should be 
given to the digestive organs. 

Lesions involving the pneumogastric at the atlas and axis are fairly 
frequent. These irritate fibers of the pneumogastric to the muscles of 
the bronchioles and thus produce narrowing of the tubes and conse- 
quently the paroxysms. Other points to note are the costal cartilages 
and hyoid bone, and prolmbly, in a few instances, lesions to the phrenic. 

Attacks may be induced reflexly by various excitants, as dust, dis- 
eases of th(^ upper rcspiratorj' tract, etc., l)ut the lesions to the vasomotor 



590 The Peactice of Osteopathy 

and motor nerves are the predisposing causes. Laughlin^ says: "It 
is questionable whether reflex causes alone are sufficient to produce 
genuine asthma without the existence of specific lesions affecting the di- 
rect nerve connections of the part involved." No doubt a neurotic 
tendency is often a predisposing factor. Overeating, and particularly 
certain foods will frequently excite an attack. 

Pathologically, true asthma is a pure neurosis. There is more 
or less chronic inflammation of the bronchial tubes, shown by injection 
and thickening of the bronchial mucosa in the majority of cases. There 
may be found the morbid states peculiar to chronic bronchitis and em- 
physema. Whether the constriction of the tubes is due to spasms of 
the bronchial muscles or to swelHng of the mucosa, or to both, the pri- 
mary, predisposing and irritating influences are common to both. These 
are vertebral and rib lesions affecting the spinal nerves at their exit and 
the sjanpathetic chain along the head of the ribs; irritating lesions to the 
vagi, constricting pulmonary' vessels, and to the cervical sympathetics, 
causing disturbance of the same, would be factors in the pathological 
chain. Reflex irritations may be found in various regions, but the prin- 
cipal osseous lesions, according to Dr. Still, are on the right side from the 
second to the sixth dorsal. 

Symptoms. — The attack may come on at any time, but usuallj^ 
it comes on in the night during sleep. The onset may be sudden or the 
attack may be preceded by premonitory sensations, such as tightness in 
the chest, flatulence, sneezing, chilhness and a copious discharge of pale 
urine. Nervous symptoms, headache, vertigo, neuralgia, and an anxious, 
nervous, restless feeling may precede the attack. There is a sense of 
oppression and anxiety, followed by dyspnea. Soon the respiratory 
efforts become violent, the patient is obliged to sit up or runs to the 
window for air. The shoulders are raised, the hands are placed upon 
something firm to keep the shoulders fixed so that the accessory muscles 
of respiration can be brought into play. The contracted tubes resist 
the entrance of air. Expiration is prolonged and wheezy. In severe 
cases the face becomes pale, the skin is covered with perspiration, the 
extremities are cold, the Hps, finger-tips and eyeUds are livid, owing to 
defective oxygenation of the blood. The pulse is small and quick and 
the temperature is normal or subnormal. The attack msLV terminate 
suddenly, sometimes with a spell of coughing; this is especially so of 
severe cases, as the cough is generally absent in brief paroxysms. 

1. Laughlin — Asthma — Journal of the American Osteopathic Association, 
Oct., 1914. 



The Practice of Osteopathy 591 

The cough is at j&rst very tight and dry and accompanied by a 
tough, scanty expectoration which is expelled with great difficulty. The 
sputum contains rounded masses of matter, the socalled "pearls" of 
Lsennec. Microscopically, they are found to be of a spiral structure, 
containing cells derived from the bronchial mucous membrane and fatty 
degenerated pus cells. A second form is contained in the inside of the 
coiled spiral of mucin, a filament of great clearness and translucency, 
that is most probably composed of transformed mucin. Curschmann's 
spirals are found in the early stages of the attack and for a time these 
were supposed, by their irritation, to excite the paroxysms. Their 
spiral form is unexplained. Curschmann beheves that these spirals are 
found in the finer bronchioles and to be a product of bronchioHtis. 

Physical Signs. — Inspection shows enlargement of the chest 
which is fixed and barrel-shaped. The breathing is labored and the 
chest moves but shghtly. The diaphragm is lowered and fixed. Per- 
cussion yields hj^per-resonance, especially in cases which have had re- 
peated attacks or when the asthma is associated with emphysema. Aus- 
cultation. — With inspiration and expiration are heard sonorous sibi- 
lant rales which are more marked on expiration. As the secretion in- 
creases, which is later in the attack, the rale becomes moist. The at- 
tack lasts for a variable period, rarely less than an hour. In severe 
attacks the paroxysms recur for three or four nights or more with spon- 
taneous remissions during the day. In some cases the relief seems to 
be absolute, but in the majority of cases there is more or less oppression 
and cough for a day or two, sometimes for many days. 

Diagnosis. — The physical signs, examination of the sputum and 
the history of the case makes the diagnosis easy. 

Prognosis. — It is not a fatal disease and only dangerous when 
complications arise. Under osteopathic treatment the prognosis is 
usually favorable, unless there are serious complications, as this is a 
disease that osteopathy has treated with signal success. In long stand- 
ing cases emphysema invariably develops. 

Treatment. — Asthma, unless complicated with bronchial and lung 
diseases, is usually readily reheved during the paroxysms. Cases of 
many years' standing have been cured in a few treatments. It should 
be borne in mind that asthma is a respiratory neurosis. 

To relieve an attack the osteopath should locate the lesion and, if 
possible, correct it. Oium^, in the acute attack, standing at the head 
of his patient inserts the tips of both thumbs well under the angles of the 
1. Journal A. O. A. 1918. 



592 The Practice of Osteopathy 

jaw and then brings direct pressure on both vagi as they pass over the 
transverse processes of the axis. Pressure must be brief and let up to be 
appHed again. Immediate relief is given in many cases. Adjust upper 
three cervicals if found deranged. 

If the muscles are so severely contracted that it is impossible to 
make out the nature of the lesion, then strong inhibition, with an up- 
ward, outward movement over the angles of the ribs involved, will be 
sufficient. The object to be gained in every ease is to reheve pressure 
or irritation to the vasomotor or motor nerves, so that the narrowed 
tubes may be relaxed. Strong inhibition, such as placing the knee in 
the patient's back, at the same time pulling on the shoulders, will have 
temporary effect, but it is always best to reduce the lesion if possible. 
In severe cases dilatation of the rectum may relieve the paroxysm, and 
in a few instances it will be necessary to treat the uterus locally. 

During the interval between the attacks is the time to remedy the 
disease. Then one is able to locate exactly the position of the disturbed 
tissues that are causing the paroxysms and apply treatment in the re- 
gions given under etiology. Many cases of asthma are cured in from 
one to three months' treatment. One treatment a week is sufficient, 
provided one is able each time to accomphsh something toward a cor- 
rection of the lesion and that the patient does not suffer during the mean- 
time. Too frequent treatments may simply act as an irritant to the 
nervous lesions. 

Attention should always be given to the diet and hygiene. Gas- 
tric digestion should be complete before retiring or it may induce an 
attack. Complications are treated according to the disease. Examine 
the upper respiratory tract, the digestive tract, and the pehdc organs 
when there is reason to believe the paroxysm may be induced reflexly. 
Laughlin sums up the treatment as follows: (1) Removal of specific 
lesion; (2) removal of exciting causes; (3) removal of reflex causes; and, 
(4) treatment of the patient to improve the condition of the general ner- 
vous system. 

DISEASES OF THE LUNGS 

Emphysema 

Used in a general way, emphysema is a term which implies the 
presence of air in the interstitial tissue, but when applied to the lungs 
there are two applications of the term, having widely different significa- 
tions, viz: Interlobular or interstitial emphysema and vesicular em- 
physema. 



The Practice of Osteopathy 593 

Interlobular Emphysema.— This is caused by rupture of air 
vesicles, deep in the king structure, the air escaping into the interlobular 
connective tissue. It is not a very serious condition, rarely produces 
symptoms and affords no physical signs. It usually results from vio- 
lent acts of coughing in which the expiratory strain is very great, as in 
whooping cough and in bronchial asthma: also, from wounds of the lung. 

The air bubbles escape into the interlobular septa and are sometimes 
seen hke little rows of beads outhning the lobules. The pleura may 
become detached and larger vesicles may form. In rare cases the rup- 
ture may take place at the root of the lung and the air passes along the 
trachea into the subcutaneous tissue of the neck and chest wall, which 
gives rise to a very peculiar and distinctive crepitation upon palpation. 
Rarely there is rupture of the superficial vesicles, producing pneumo- 
thorax. 

Vesicular Emphysema. — Dilatation of the infundibular passages 
and alveoli or an increase in their size either symmetrical, involving both 
lungs, or localized. Vesicular emphysema is divided into compensatory, 
hypertrophic and atrophic forms. 

Compensatory. — This occurs when a region of the lung has been 
disabled from an}^ cause and does not expand fully during inspiration; the 
healthy portion of the lung must then distend and do vicarious work or 
the chest wall will sink in to occupy the space. This happens with por- 
tions of healthy lungs in the neighborhood of tubercular areas and ci- 
catrices, areas of collapsed lung or parts prevented from expansion by 
pleuritic adhesions (in this case the compensatory emphysema is chiefly 
at the anterior margins of the lungs) . As a rule this distention is physio- 
logic and beneficial, the alveolar walls being simply stretched. Later 
they may, atrophy, the air cells becoming fused. 

Hypertrophic Emphysema. — This is enlargement of the lung, due 
to dilatation of the air vesicles and atrophy of the walls. 

Osteopathic Etiology and Pathology. — An important predis- 
posing cause of emphysema is often found to be due to derangements of 
the tissues, usually vertebra? and ribs, which affect the innervation to 
the lung tissues. Such lesions are found in the vagi and spinal dorsal 
nerves. The atlas may be involved, but it is generally the ribs and dor- 
sal vertebra. Distinction should be made between cause and effect in 
the skeletal changes. No doubt in many instances a vicious circle is 
thus established. Congenital weakness of the lung tissues, probably 
due to non-development of the elastic tissue, is a predisposing factor. 
This disease has a m;u•k(■(ll^■ licicditai'v character and frequently starts 



594 The Practice of Osteopathy 

early in life. The heightened pressure within the air cells upon an already 
weakened lung tissue produces emphysema. Hence, the obstinate cough 
of chronic bronchitis and expiratory straining of asthma are sometimes 
the immediate cause. In all attacks of severe coughing or straining 
efforts, the glottis is closed and the air is forced into the upper part of 
the lungs, forcibly expanding them, and here is where emphysema is 
found to be most advanced. This disease is also found in players of 
wind instruments, in glass blowers and in those whose occupation neces- 
sitates heavy lifting or straining. 

Pathologically, the thorax is barrel-shaped. The lungs are en- 
larged and do not collapse when the thorax is opened, as they have lost 
their elasticity. The organs are pale, soft and downy to the feeling and 
pit on pressure. Enlarged air vesicles may readily be seen beneath the 
pleura. Microscopically, there are seen atrophy of the vesicular walls 
and a diminished amount of elastic tissue. There is more or less oblit- 
eration of the capillaries, and the epithelium of the air cells undergoes a 
fatty change. There is usually chronic inflammation of the bronchial 
tubes, which may be roughened and thickened. The diaphragm is 
lowered and the subjacent viscera are displaced. The most important 
morbid changes are found in the heart, the right chamber being dilated 
and hypertrophied. This is caused by the increased tension in the pul- 
monary artery, which is enlarged and the seat of atheromatous degener- 
ation. In long standing cases the hypertrophy is general. Changes in 
the hver, kidneys and other viscera are those associated with prolonged 
venous engorgement. 

Symptoms. — The onset of the disease is usually gradual. The 
first symptom to be noticed is the shortness of breath. In rare cases it 
may exhibit a more acute development, as after whooping cough, and 
then the first symptom will be dyspnea. In some cases this persists all 
the time, while in moderate emphysema the dyspnea is noticed only on 
slight exertion, such as going up-stairs, running or walking rapidly. The 
lungs are always filled with air which is charged with carbon dioxid and 
does not change, as the patient is constantly making ineffectual efforts to 
draw in air. The inspiration is shortened and the expiration is greatly 
prolonged and is often harsh and wheezy. The. pulse-rate is accelerated; 
the temperature is usually normal. Cyanosis is a characteristic symptom 
in well estabhshed cases and is of an extreme gradq not seen in any other 
affection. Bronchitis is frequently found in combination, especially in 
winter. In this case there will be the symptoms of the associated bron- 
chitis, cough, expectoration and sometimes oppression. As the patient 



The Practice of Osteopathy 595 

advances in age and there are successive attacks of bronchitis, the con- 
dition gets worse. In advanced cases, the result of cardiac failures, 
there may be venous engorgement, dropsj^ and effusions into the serous 
sacs. 

Physical Signs. — Inspection. — There is a marked change in the 
shape of the thorax. The chest is rounded with increased circumfer- 
ence, giving the characteristic barrel-shaped chest. The sternum 
bulges, as do also the costal cartilages. The intercostal spaces are wide, 
especiallj^ in the hypochondriac region, and narrow above. The clav- 
icles and muscles of the neck stand out with great prominence and the 
neck itself seems to be shortened on account of the elevation of the thorax 
and sternum. The curve of the spine is increased and there is a winged 
condition of the scapulae. These changes give the patient a stooping 
posture. The chest does not expand, but is raised up by the scaleni and 
sternocleidomastoid muscles which stand out prominently and are 
hj^pertrophied. The heart's apex beat is invisible and there is usual]\ 
marked epigastric pulsation. On palpation, vocal fremitus is found 
diminished, but not absent; the apex beat is rarely felt. There is dis- 
tinct shock over the ensiform cartilage. This is due to the displacement 
of the heart and engorgement of the right ventricle. There is marked 
pulsation in the epigastrium. On percussion there is sometimes in- 
creased resonance, almost amounting to tympany. The upper level of 
hepatic dullness is depressed. The heart dullness may be obhterated 
and the upper Hmit of splenic dullness may also be lowered. The per- 
cussion note is greatly extended. Auscultation reveals that the in- 
spiration is short and feeble while there is prolonged expiration, the normal 
ratio being reversed. In associated bronchitis rales are frequently heard. 

Diagnosis. — Unless complicated the diagnosis is generally easily 
made. The enlargement of the thorax, with dyspnea and hyper-reso- 
nance and a prolonged expiration will differentiate emphysema from- 
chronic bronchitis. Pneumothorax is of sudden development while 
emphysema is of slow development. Pneumothorax is usually unilat- 
(u-al, and it gives a tympanitic percussion note. In auscultation there 
is amphoric breathing and metallic tinkhng and absence of any vesicular 
murmur. 

Prognosis. — The disease is rarely fatal, although death may result 
I'lotu heart failure, dropsy or pneumonia. Thorough and persistent 
treatment will generally relieve the primary condition. The disease, as 
a rule, runs a long course but does not necessarily shorten hfe. 

Atrophic emphysema is a senile change. 



596 The Practice of Osteopathy 

Treatment. — In cases of recent occurrence one maj' be able to 
build up the altered lung tissue by treatment of the innervation to the 
lung structure, viz. : the vasomotor nerves from the second to the sev- 
enth dorsal, the vagi, and the cervical and dorsal sjanpathetics. When 
a number of air vesicles have been converted into one sac, it is impossible 
to restore the altered lung structure and a treatment to reheve the symp- 
toms and to prevent the further progress of the disease is indicated. In 
all cases treatment should be applied to correct any vertebrae or ribs of 
the upper dorsal region that may be displaced, and to raise and spread 
the ribs so that the lung structure may be better nourished and strength- 
ened and that the aeration of the blood will be more perfect. Treatment 
of the vagi nerves is important, as their physiological action on the lungs 
is to increase their movement. 

The general health of the patient is an important consideration and 
everything should be done to promote as healthy a condition as possible. 
The digestion should be carefully looked after and everything done to 
restore a normal state of the blood. A change of climate may prove 
beneficial. 

Strengthening the cardiac action will be of service in relieving any 
dropsical tendency that might occur on account of obstruction to the 
pulmonary circulation. If bronchitis or asthma occurs, their respective 
treatments are indicated. A general treatment of the splanchnic and 
lung vascular areas should be given to prevent any disturbance in the 
circulation which might cause congestion of the liver, congestion of the 
hemorrhoidal veins, or catarrh of the stomach and bowels. 

"Free evacuation of the bowels and measures to reUeve any flatulent 
distention are very needful in cases of emphysema to take off from the 
diaphragm any pressure from below, and to allow it to descend as freely 
as possible. With this view also the food should be concentrated, nour- 
ishing, and not bulkJ^"^ 

It is a good plan to instruct the nurse or attendant to aid inspira- 
tion by raising the arms strongly above the head during inspiration and 
to compress the chest during expiration so as to coincide with natural 
breathing, which will render the aeration of the blood greater and in- 
crease the elasticity of the vesicles. 

1. Yeo — A Manual of Medical Treatment or Clinical Therapeutics, Vol. 1, 
p. 597. 



The Practice of Osteopathy 597 

Acute Lobar Pneumonia 

(Croupous Pneumonia) 

This is an acute, infectious disease wherein various vertebral, rib 
and muscular lesions predispose to a lowered nutritive state of the paren- 
chyma of the lung, permitting the invasion of the diplococcus pneumoniae, 
with consequent local inflammation and pronounced constitutional dis- 
turbances, chill, extreme prostration and fever, which terminates abrupt- 
ly by crisis. Secondary infective processes are frequent. 

In describing a typical case of pneumonia it is considered as a self- 
hmiting disease. By osteopathic treatment it is often aborted or, at 
least, its course much shortened. In such a case it is not typical pneu- 
monia and could not be described as such. 

Osteopathic Etiology and Patliology. — Pneumonia occurs more 
often in the young up to the sixth year and in the aged. It is more fre- 
quent during the winter and spring months. "Colds," exposure and 
wetting are predisposing influences that lower resistance. Climate 
exerts Httle predisposing influence. Males are, on the whole, more fre- 
quently attacked. Pneumonia may follow injuries of the chest. Var- 
ious derangements of the ribs and vertebrae are always found in pneu- 
monia; such derangements correspond with the regions of vasomotor, 
motor and trophic fibers of the lungs, viz., second to seventh dorsal, in- 
clusive, and the upper cervical vertebrae, the latter region affecting the 
vagi. The muscles of the chest region are always severely contracted. 
These various disorders produce a lowered vitality of the bronchial and 
lung tissues, thus favoring the existence of the micrococcus lanceolatus. 
Unhj^gienic surroundings, alcohohsm, any or all habits that tend to de- 
press the nervous system, or lowered vitality from some pre-existent dis- 
ease, Hke diabetes, Bright's disease, organic heart affection or one of 
the infectious fevers, favor its development. One attack undoubtedly^ 
predisposes to another and repeated attacks may occur in the same in- 
dividual. The exciting cause is the invasion of the lung by pathogenic 
bacteria, especially by diploccocus pneumoniae. Pneumococci are fre- 
quently found in the throat and mouth of the healthy. 

Pathologically, the lung in croupous pneumonia exhibits three 
distinct stages — congestion, red hepatization and gray hepatization. In 
th(> stage of engorgement the tissue is red in color, firm and solid and 
less crepitant than the healthy lung. The cut surface is bathed in blood 
and stained scrum. Microscopic examination shows the capillaries to 
1)0 dilated and tortuous. The alveolai- c'liitholiuni is swollen and the 



598 The Practice of Osteopathy 

air cells filled with a variable number of red corpuscles, detached alveolar 
cells and a few leucocytes. During the stage of red hepatization the 

tissue is solid. It is reddish brown in color and of a dry, mottled ap- 
pearance. It is very friable and does not crepitate, as the affected por- 
tion is airless. Its weight and specific gravity are increased so that it 
sinks in water. The torn surface presents a granular appearance, there 
being fibrinous plugs in the air cells. On microscopic examination the 
air spaces are found filled with coagulated fibrin. The tissue contains 
red blood corpuscles and pus cells and the walls of the air cells are infil- 
trated. In sections properly treated the diplococcus is detected, and in 
some cases also the streptococcus and staphylococcus. In the stage of 
gray hepatization, the lung is still dense and heavy, but the surface 
is moister and softer, while the lung tissue is even more friable and the 
red color gives place to a mottled gray. The exudate loses its granular 
character and a yellowish white purulent liquid flows from a cut sur- 
face. Microscopically, the air cells are filled with leucocytes, while the 
red corpuscles and fibrin filaments have disappeared. The stage of gray 
hepatization is the stage of beginning resolution. The exudate is 
softened. The cell elements are disintegrated and absorbed by the 
lymphatics and largely eliminated through the kidneys. In unfavor- 
able cases the consolidated lung may become infiltrated with pus, and 
abscesses occur. In some instances the tissue is gangrenous, or it may 
become the seat of fibroid induration. These, however, are rare. 

Symptoms. — The disease begins abruptly, usually with a severe 
chill, lasting from half an hour to an hour, the fever rising rapidly. There 
is a sharp pain in the side, the skin becomes harsh and dry, the face is 
flushed, the eyes are bright and the expression anxious. A short, dry, 
painful cough soon develops. The expectoration presents a character- 
istic, rusty or blood tinged appearance and is extremely tenacious. The 
temperature rises rapidly, frequently to 104 or 105 degrees F., and con- 
tinues high for from five to ten days and generally terminates by crisis. 
The pulse is full, but the pulse-respiration ratio is not maintained. There 
is marked dyspnea, the respirations ranging from forty to fifty per min- 
ute. There are many fine rales. Headache, gastro-intestinal disturb- 
ances, sleeplessness, epistaxis, rarely dehrium except in drunkards, may 
also be present. 

The symptoms given are those of a typical case of pneumonia, but 
all are subject to modification. The onset may be gradual and the chill 
absent. In all cases, and especially drunkards, the temperature may 
not be high, while the pulse is often feeble and rapid instead of full and 



The Practice of Osteopathy 599 

strong, and the physical signs may not make their appearance until 
the second or third day. 

Special Symptoms. — The fever rises abruptly in the initial chill, 
the temperature reaching 104 or 105 degrees F., and is continuous with a 
variation of a degree or two. The fever terminates by crisis after hav- 
ing continued from five to nine days. The temperature commonly falls 
during the night and is accompanied by a profuse perspiration. The 
temperature may fall from five to eight degrees in eight to twelve hours. 
There is a wide range here depending upon promptness and skillfulness 
of treatment, the reaction of the tissues, and previous health. Early 
treatment is invaluable in modifying the course of the disease. 

The sputum at first is mucoid and frothy. About the second day 
it becomes of a characteristic color, quite copious and consisting of a 
frothy, fluid mucus, containing small viscid masses. It is very viscid 
and glutinous, in some cases almost from the onset. In old and prev- 
iously weak persons, there may be no expectoration. Under the micro- 
scope the sputum is seen to contain red blood-corpuscles, leucocytes, 
alveolar epithehum, the micrococcus lanceolatus as well as other micro- 
organisms, pus corpuscles and small fibrinous casts. A stabbing pain 
is a common early symptom, as well as a dry, short cougli. The urine 
is febrile, scanty and high-colored. Urea and uric acid are increased. 
A trace of albumin is often present, and there may be symptoms of acute 
nephritis. Herpes is common. The naso-labial herpes appear from the 
second to the fifth day, and they may occur upon the cheek, genitals 
and also upon mucosa of the tongue. It is supposed to indicate a fav- 
orable prognosis. There is redness of the cheek, usually on the affected 
side. The mucous membrane of the mouth is dry. The tongue is white 
and furred. Anorexia and thirst are present. The patient is usually 
constipated, but diarrhea may occur. Vomiting is common. The 
spleen is usually enlarged, but the liver is not perceptibly increased in 
size, unless there is extreme engorgement of the right heart. The pulse 
is bounding. The average pulse-rate is from 100 to 108 per minute. 
In consohdation the left ventricle receives a lessened amount of blood 
and the pulse may become small. In the aged and debihtated, a small, 
weak and rapid pulse may be present. The lieart sounds are loud and 
clear, and in favorable cases the pulmonary second sound is accentu- 
ated, owing to the increased tension in the pulmonary vessels. Upon 
distension of the right side of the heart and partial failure of the right 
ventricle, the second sound becomes less distinct which is a very unfav- 
orable symptom, for very much depends upon the strength of the I'ight 



GOO The Practice of Osteopathy 

ventricle in pneumonia. The blood usually exhibits leucocytosis which 
disappears with the crisis. In malignant pneumonia this is absent and 
its continued absence is an unfavorable sign. The proportion of fibrin 
is also greatly increased. The diplococci can rarely be seen. Head- 
ache is common as an initial symptom and may be persistent. The 
disease is often ushered in by convulsions, especially in children; con- 
sciousness is usually retained throughout the whole attack, even in se- 
vere cases, though in some cases there is delirium. In drunkards delir- 
ium tremens may be present from the onset. In these cases the pa- 
tient often wanders about until the prehminary excitement gives way 
to coma. 

Physical Signs. — Stage of Congestion.— Diminished expansion, 
the movements of the affected side are defective, the face is flushed and 
the patient lies on the affected side. Tactile fremitus is slightly in- 
creased. There may be tympany over the involved area from dimin- 
ished intrapulmonary tension. In the latter part of this stage there is 
impairment of resonance. Fine crepitant rales are heard at the end of 
forced inspiration. Great care has to be taken in examination when 
there is deep seated consolidation. 

Stage of Red Hepatization. — The breathing is markedly ab- 
normal. Very Httle or no expansive motion of the chest over the affected 
region. Vocal fremitus is markedly exaggerated. The skin is hot and 
dry and the pulse frequent. Dullness over the affected parts with an 
increased sense of resistance is present. There is high-pitched, pro- 
longed, bronchial breathing when the lung becomes solidified. When 
the larger bronchi are completely filled with exudate, tubular breathing 
is absent. Crepitant rales may also be heard. 

Stage of Gray Hepatization. — Largely the same physical signs 
are repeated in this stage as in the second. The normal manner of breath- 
ing returns, as does also the normal expansive movement of the affected 
side. Crepitant rales reappear. The temperature of the skin is lessened, 
breathing changes from bronchial to vesicular and bronchial resonance 
continues for some time. 

Complications. — Pleurisy is the most frequent complication. 
Pneumonia on one side and pleurisy on the other is possible. The pain 
is more acute and localized. The respiration is greatly affected and the 
usual signs of effusion are present. Empyema may be a complication. 
Pericarditis is more common in the pneumonia of children. Though 
usually plastic it may be sero-fibrinous, but rarely the fluid is purulent. 
There is increased dyspnea, the pulse becomes weaker, and the heart 



The Practice of Osteopathy 601 

sounds are gradually suppressed. Endocarditis is a comparatively 
frequent complication. It is more liable to attack patients with old 
valvular disease and to affect the left heart. The physical signs are 
sometimes absent and even when present are liable to be very deceptive. 
It may, however, be suspected in cases where the fever is protracted; 
when septic manifestations, such as chills, sweats or irregular tempera- 
ture, develop ; when emboHc symptoms appear, or when a rough, diastohc 
murmur develops. Meningitis is a compHcation that comes on at the 
height of the fever. This comphcation is rarely recognized unless the 
basilar meninges are involved. It is frequently associated with ulcer- 
ated endocarditis. Cerebral emboHsm causing hemiplegia has been ob- 
served. Other possible compHcations are neuritis, arthritis, nephritis, 
parotitis and various digestive disorders. 

Diagnosis. — A typical case of pneumonia is easily recognized. 
The abrupt onset with rigor, the rapidly developed fever, the sputum, 
physical signs and abnormal pulse-respiration ratio, as a rule make the 
diagnosis easy. Frequent examination of the lungs should be made in 
Bright's disease, diabetes, organic affections of the heart, cancer and al- 
coholism, as all these affections are hable to become compHcated with 
acute pneumonia. Pleurisy is often confounded with pneumonia. The 
resemblance between friction sounds and crepitant rales is often very 
close. In pleurisy vocal resonance and vocal fremitus are diminished; 
there is no "rusty" sputum; the percussion dullness may change with 
the posture of the patient, and the breathing is distant and weak. A 
typhoid state may be mistaken for typhoid fever. Hypostasis occurs 
late in typhoid fever while dullness sets in early in pneumonia. The 
history of the onset will be of aid, as pneumonia as a compHcation sets in 
late in the disease. The Widal test will be of value. Acute phthisis 
may begin with a chill and may resemble pneumonia very closely, es- 
pecially the physical signs. Examination of the sputum will show the 
bacilli of tuberculosis. The X-ray will often be of aid as a diagnostic 
measure. 

Prognosis. — This largely depends upon the previous health of the 
patient. At the extremes of life the prognosis is much more unfavorable. 
It is especiall}^ fatal in drunkards. By competent osteopathic treat- 
ment the mortality rate may be materially lessened and this disease, 
dreaded by both physician and patient, need not seem so fearful. The 
death rate from pneumonia during the past few years has been appalling. 
In New York and Chicago nearly one-eighth of the deaths the year around 
are due to pneumonia, and during certain months of the year twenty-sev- 



602 The Practice of Osteopathy 

en or eight per cent, of all deaths are due to this disease. Drug medica 
tion is notoriously unreliable, the most competent physicians freel}" ad- 
mitting that they are practically powerless to stay the ravages. Given a 
patient with a fair constitution, osteopathic treatment will offer reason- 
able hope to the sufferer. There is no question that osteopathy merits 
much commendation in the treatment of pneumonia. Many severe 
cases have been cured and many more have undoubtedly been aborted. 
The treatment is directly applicable and specifically indicated, and coup- 
led with good nursing and hygiene, the mortaUty rate of the old schools 
is being markedly lessened. 

Treatment. — -The treatment of pneumonia must be both consti- 
tutional and local. By this is meant that the systemic strength and 
vigor must be maintained in addition to treatment of the chief lesion 
of the disease, which is located in the lungs. 

During the various stages of the disease, the treatment should be 
directed to the nerves of direct innervation that control the capillaries, 
and to the vasomotor nerves of the pulmonary circulation, in order that 
the hyperemic and inflamed state of the pulmonarj^ capillaries and ad- 
jacent tissues may be lessened and the circulatory system equalized. The 
disordered tissues that should be corrected in order that the centers of 
the spinal cord and the nerves that influence the function and structure 
of the lungs may be relieved, are: contraction of the thoracic and dorsal 
muscles, subluxations of the ribs and dorsal vertebra? from the second 
to the seventh, inclusive, and the upper cervical vertebra that may be- 
come disordered and impinge upon the vagi nerves. However, owing 
to the fact that the vasomotors are not especially abundant here, all 
increased chest mobility and deep breathing and abdominal aid will 
materially assist the circulation. Also, carefully treat the middle and 
inferior cervical regions for the lymphatics of the lungs. Each of these 
regions should be carefully examined and thoroughly treated whenever 
found involved. The specific micro-organisms that influence the course 
of pneumonia are naturally very important factors; but observing and 
improving the general health, and establishing an unobstructed circula- 
tion through the diseased lung tissues will hasten the crisis by favoring a 
rapid formation of antidotal substances to neutralize the poisonous sub- 
stance produced by the micrococcus lanceolatus. Healthy tissues, which 
occur only where there is uninterrupted freedom of vascular supply and 
nerve force, are obtained by correction of any and all anatomical disor- 
ders. This will rapidly decrease any lethal tendency'' in the patient and 
often abort the disorder so that all that is needed is sufficient time for 



The Practice of Osteopathy 603 

nature to heal the diseased tissues. The principal predisposing cause of 
many specific diseases, is some disorder of the anatomical tissues that 
interferes with normal physiological functions; and the determining of 
the different types of disease is often due to the location of the lesion 
and the character of the micro-organism involved in each disease. What 
is necessary in many cases is a correction of the mechanical predisposing 
condition and the exciting and determining influences will be rendered 
inactive. 

The importance of close attention to both vagi can not be overesti- 
mated. Any obstruction above or below the origin of the superior laryn- 
geal nerve is followed by loss of motor power of the lungs, thus causing 
difiicult and labored breathing. The lungs become surcharged with 
blood, because the air pressure in the lungs is low and the thorax is dis- 
tended. This condition is followed by serous exudation. Thus ob- 
struction of the vagi may be one factor in the cause of pneumonia. Ob- 
struction of the vagi below the origin of the recurrent laryngeal nerves 
affects the lower and middle lobes of the lungs, and produces also a ca- 
tarrhal inflammation of the upper lobes. The recurrent laryngeal nerves 
may be obstructed by dilatation of the aorta or subclavian artery as they 
wind about them; also b}^ dislocations of the first and second ribs, which 
may affect the nerves not only directly, but by causing an obstruction 
to the subclavian vessels with a consequent disturbance of the aorta and 
the heart. The recurrent laryngeal nerves may be treated directly at 
the inner lower part of the sternomastoid. 

One of the chief objects of the treatment should be to prevent heart 
failure and to lessen the pulse-respiration ratio. The average pulse-rate 
in typical cases is from 100 to 110 per minute and when it exceeds this to 
any extent, say 120, there is cause for alarm. At first the pulse is full 
and bounding, later it is small on account of a lessened amount of blood 
reaching the left ventricle and systemic circulation, owing to the ex- 
tensive consoHdation. In treating heart failure particular attention 
should be paid to the condition of the ribs on the left side over the region 
of the heart, the second to the fifth, inclusive. A correction of any dis- 
turbance to the inhibitory nerves of the heart, (the vagi) and the accel- 
erator fibers of the heart (the cervical sympathetic) should be made. 
This means close attention to probable derangements of the vertebrae 
from atlas to first dorsal. General treatment of the entire system will 
reheve the heart of some work and favor an equahzation of the vascular 
system. Also by the use of hydrotherapy the maintenance of the heart's 
action may be accomplished. Cold compresses, and not warm ones, 



604 The Practice of Osteopathy 

should be used, as the latter relax the vessel walls, producing more or 
less paresis of the vessels, while the former stimulate the vaso-dilators, 
producing dilatation and tone of the vessels, thereby causing a vigorous 
increase in the flow of blood. This reheves the heart bj^ increasing the 
cutaneous circulation, besides increasing arterial tension. The right 
heart is indirectl}^ aided by the increase of the tension in the general 
vascular system, and the vessels of the pulmonary circulation have more 
force expended upon them and a greater contraction of their vessels 
occurs on account of the dilatation of the cutaneous vessels. The tem- 
perature of the water used should be 60 degrees F., and the compress 
applied for thirty minutes or as long as necessary. 

Attention to the abdominal area and diaphragm will have a definite 
effect upon the circulation and ehmination. It is beneficial in its in- 
fluence upon lungs and heart and in combatting toxemia. Carefully 
graduated deep breathing is of distinct benefit. 

In addition to the fever treatment in the cervical and dorsal re- 
gions, the gradually cooled tub-bath will be of aid. The temperature at 
first should be ninety degrees F. and then gradually cooled to eighty 
degrees F. The duration should not be over ten or fifteen minutes. 
Care should be taken that the patienl does not exert himself. He should 
be lifted in and out of the baths. These baths also have a marked effect 
upon the respiratory and nervous centers. The ice-bag over the chest 
and spine has a beneficial influence; still, with feeble children be exceed- 
ingly careful when applying or using cold methods. 

During all stages of the disease, the best possible care should be 
taken of the patient. See the patient frequently, probably twice a day 
or oftener. Each time thoroughly relax the dorsal muscles and re-adjust 
the ribs, for as every osteopath of experience will note (and Dr. Still 
particularly emphasizes) the contracted muscles frequently and con- 
tinually displace the ribs. The treatment should not be prolonged to a 
point of overfatigue, but a definite reaction of tissues should be secured 
but no further. 

Carefully raise all the ribs and moderately hyperextend the spine. 
Release the cervical, pectoral and axillary lymphatics, and stimulate 
spleen and fiver. 

Experience has shown that the first treatment is of the greatest im- 
portance and if the osteopath will control the predominant symptoms at 
that time the result will be much simplified. For that reason it is best 
not to leave the patient until the chest pain, fever, high pulse or what- 
ever may be present, are well in hand, although it may mean a long visit 



The Practice op Osteopathy 605 

with fairly frequent treatments. Treat the conditions existing and 
wait; then treat again and the result will more than repay. There is 
always more than a chance of aborting the disease, but the first treat- 
ment is often the crucial test. F. E. Moore and many others report 
numerous cases treated without a fatahty and the average duration of 
the disease not exceeding five days. The apartment should be well 
aired and a temperature of 65 degrees F. maintained. In the very young 
the temperature should be higher. The diet is exceedingly important. 
Give a liquid, light and nutritious one, a milk diet being preferable. 
Otherwise give meat juice, broths, egg albumin and whey. Avoid starchy 
and saccharine foods, and give plenty of water. Good nursing and com- 
plete rest of body and mind, with careful attention to the activity of the 
bowels, kidneys and skin, will indirectly aid the clogged up lung fascia 
to perform its function and hasten an early recovery from the disease. 
In epidemic forms be particularly vigilant in the employment of anti- 
septics. 

Bronchopneumonia 

(Catarrhal Pneumonia) 

Definition. — An inflammation of the minute bronchi and air ves- 
icles. The affection begins with an inflammation of the capillary bron- 
chi, which extends to the air vesicles. The micrococcus lanceolatus, 
streptococcus pyogenes, influenza bacillus, and staphylococcus aureus 
et albus are the principal exciting microorganisms. 

Osteopathic Etiology and Pathology. — The disease is most 
prevalent among the very young and the old, and may be either pri- 
mary or secondary. It may occur as a sequence or in association with 
measles, diphtheria, whooping cough and scarlet fever. Exposure to 
cold, impure air, rickets and diarrhea are marked predisposing causes in 
children. In the old, debilitating affections and chronic diseases are 
predisposing causes. Bronchopneumonia occurs sometimes as a com- 
plication in smallpox, erysipelas, typhoid fever and influenza. The 
principal lesions found upon examination are subdislocated ribs affecting 
the pulmonary vasomotor nerves. The third, fourth and fifth ribs are 
especially apt to be subdislocated. The muscles throughout the tho- 
racic region are generally severely contracted. 

Another group of cases, the so-called aspiration or deglutition 
pneumonia, are caused by the inhalation of food particles or other 
substances. A lessened sensitiveness of the larynx (as in comatose 
states) may allow small particles of food to reach the smaller bronchi 



60G The Peactice of Osteopathy 

and produce inflammation, which may even cause suppm-ation and some- 
times gangrene. Cases are Hable to occur after operations about the 
nose and mouth. It is often secondary to carcinoma of the larynx and 
esophagus and after tracheotomy and glosso-pharyngeal palsy. A ser- 
ious form of bronchopneumonia is caused by the tubercle bacillus. 

Pathologically, both lungs are usuall}^ involved and become heavy. 
On the pleural surfaces, especially at the base, sunken purphsh or slaty 
patches are noticed, representing collapsed lung tissue. On section small, 
projecting portions of consolidation are seen, separated from each other 
by uninflamed and collapsed tissue. The section of lung tissue is of a 
dark reddish color. The terminal bronclii are filled with tenacious, puru- 
lent matei'ial. Microscopically, the terminal bronchi and air cells are 
filled with a plug of exudation composed of leucocjrtes and desquamated 
epithelium. The walls of the bronchi are swollen and contain many 
leucoc}^es. 

Symptoms. — The symptoms are frequently marked by those of 
the primary affection. The onset may be either abrupt or gradual. The 
child becomes feverish; there is increased frequency in respiration and 
there is an aggravated cough. The temperature rises to 102 or 104 de- 
grees F.; respiration may rise as high as 60 or 80. The cough is hard, 
distressing, frequently painful and accompanied by a mucopurulent ex- 
pectoration. The pulse is greatl}^ accelerated — 120 to 180 per minute. 
As the disease advances, signs of deficient aeration of the blood are no- 
ticed. At first there is a pale and anxious expression of the face, the 
lips are blue and the child makes strenuous efforts to breathe. The 
blood soon becomes highly charged with carbon dioxide and, by its be- 
numbing influence upon the nerve centers, sensibiHty is reduced and the 
cough and suffering subside. The face becomes Uvid and death may 
occur within twenty-four hours from paralysis of the heart. 

At the beginning of the attack dullness is absent and subcrepitant 
and sibilant rales are present. Areas of consolidation soon become 
manifested. There is shght impairment of resonance and the breath- 
ing is harsh. Upon inspection there is, in grave cases, retraction of the 
sternum due to defective expansion. 

Diagnosis. — This is usually eas}', developing as it generally does 
in the course or at the conclusion of another disease, with a gradual onset 
as a rule, and irregular fever and a long duration, besides usually occur- 
ring in children under five. If the areas of consohdation are large, in- 
volving the greater part of a lobe, it is sometimes very difficult to distin- 
guish bronchial pneumonia from lobar pneumonia. Lobar pneumonia. 



The Practice of Osteopathy 607 

when occurring in children, is usually between the ages of five and fif- 
teen. The onset is abrupt in a child of good health; it resolves rapidly; 
there is rusty colored sputum and continued fever falHng by crisis. Tu- 
berculous bronchopneumonia is very hard to differentiate from 
simple bronchopneumonia. A great many cases can be correctly diag- 
nosed only after the lapse of considerable time. The presence of signs 
of softening, considerable disease of the apices, and examination of the 
sputum, or in the case of a child, of the vomited matter, would diagnose 
this form. If elastic fibers and tubercle bacilli are found in the sputum 
or vomited matter, the diagnosis is at once decided in favor of tuber- 
culous bronchopneumonia. X-ray diagnosis should be considered. 

Prognosis. — The prognosis depends on the cause. In children 
that are previously weak and debilitated the disease is very fatal. When 
the disease follows measles and whooping cough, the fatality is not so 
great. In adults the prognosis is about the same as in the croupous form. 
The deglutition variety is apt to be fatal. 

Treatment. — A great deal can be done to prevent the disease, by 
careful attention to debihtated children in keeping them warm and pro- 
tected at all times. There is usually a preexisting bronchitis. In meas- 
les and whooping cough and during convalescence, the child should be 
well taken care of. 

A thorough, persistent treatment, but not to a point of overfatigue, 
of the dorsal vasomotor nerves posteriorly should be given. Gentle 
work over the cervical and ^axillary lymphatics to free the edematous 
barrier, correction of the tensed scaleni and deranged first ribs and clav- 
icles, and stimulation of spleen and liver, with sufficient general treat- 
ment to start reaction, will be effective. Derangements to the third, 
fourth and fifth dorsal nerves are most likely to be found; the principal 
vasomotor innervation to the bronchials and air vesicles is from this 
region. Treatment over the chest anteriorly is of great aid, especially 
an upward and outward manipulation to release the ribs should be given. 
Attention should be given the vagi nerves to increase the activity of the 
lungs as well as for the effect gained upon the circular fibers of the bron- 
chi. Care should be taken, that the first rib is not impinging upon the 
first thoracic ganglion, or interfering with lymphatic drainage. 

Ice-bags over the chest are helpful. The chest should be protected 
from changes in temperature by a jacket of cotton batting. The diet 
should consist of milk, egg albumin and broths. Keep the temperature 
at about 70 degrees F. and the air of the room moist and free from 
draughts. When the fever is high, sponging or the wet pack is helpful. 



608 The Practice of Osteopathy 

The bowels from the beginning of the attack should be carefully watched. 

There is danger of a failing heart: this is generally associated with 
mucous rales and cyanosis. Douching alternately with hot and cold 
water will usually excite coughing and overcome the difficulty. The 
gradually cooled bath will have a marked effect in reducing the tempera- 
ture, quieting the nervous symptoms, increasing the respiratory power 
and promoting sleep. 

Raise and carefully stimulate the abdominal viscera, and elevate 
the diaphragm. This is effective in both cyanosis and toxemia. 

In the first stage of pneumonia, Hazzard^ says, "There is better 
opportunity to correct the specific lesion, as the patient's strength will 
allow of such treatment. The work is also aided by the fact that the 
alveoli are still open, and lung action, stimulated b}- treatment, may 
become a valuable aid in dispelung the engorgement." This is a most 
valuable suggestion, but be exceedingly careful in subsequent treatments 
not to treat too hard and thus lame and bruise the patient. 

Series I, II, III, and V of the American Osteopathic Association 
Case Reports present several interesting cases of pneumonia which typ- 
if}^ the importance of immediate and direct correction of the osteopathic 
lesions. 

Herman" cites an interesting case of delayed resolution, due to a de- 
pressed condition of all the ribs on the affected side with marked luxation 
of the eighth. The lesion at the eighth was the cause of a prolonged at- 
tack of hiccoughs which prevented resolution. It is pointed out that 
there is an abundant intercostal nerve supply to the diaphragm from the 
eighth and ninth intercostals. C. E. Achorn instances an autopsy of 
patient dying of pneumonia, where a bony ankylosis was found at the 
second dorsal; this lesion was probably an important predisposing factor. 

Broadly speaking, one should keep in mind the following: First, 
early treatment will frequently abort what would ultimately be pneu- 
monia — still, in the preceding it is not these cases that are especially re- 
ferred to, but those following the course of a typical pneumonic process; 
second, both specific and general treatment prior to the crisis will mater- 
ially lessen the severity of the disease; third, the crisis corresponds to 
beginning resolution (during resolution expectoration and Uquefaction 
and absorption of the exudate are paramount features) and must be met 
promptly and vigorously, special attention being paid to the heart ; and, 

1. Hazzard^Practice of Osteopathy p. 91. 

2. Herman — An Unusual Feature in a Case of Pneumonia — Journal of the 
American Osteopathic Association, July 1906. (This refers to lobar pneumonia.) 



The Practice of Osteopathy 609 

fourth, during convalescence, good, general attention and care of patient 
as to treatment, hygiene, diet, and climate, are important. 

Chronic Interstitial Pneumonia 

(Fibroid Induration) 

Definition. — A chronic, inflammatory disease of the lungs, char- 
acterized by an overgrowth of fibrous or connective tissue. 

Etiology. — With few exceptions chronic affections of the lungs 
cause more or less fibroid overgrowth. Tliis is especially frequent after 
bronchial pneumonia and pulmonary tuberculosis. It is also excited by 
abscesses, hydatids, sj^phihs, emphysema, sarcoma and old fibrinous 
pleurisy. It may also be caused by compression, by aneurism or neo- 
plasms. It may arise as a primary affection, due to the inhalation of 
irritating dusts (stone dust, coal dust and metal dust). There will be 
found deeply seated osseous lesions of the upper and middle dorsal region 
and corresponding ribs, and frequently of the cervical vertebrae. 

Pathologically, as it involves limited or extensive areas, it is recog- 
nized as local or diffuse. It is a unilateral affection. The involved por- 
tion is shrunken and on section it is found to be tough, firm, of a green- 
ish color and containing an overgrowth of fibrous tissue. If it affects 
the left side the heart may be displaced. The unaffected lung is usually 
enlarged (compensatory emphysema). There is hypertrophy of the 
right ventricle of the heart. 

Symptoms. — There is a chronic cough, which varies greatly in its 
severity; moderate dyspnea, and a variable expectoration. There is 
no fever and the general health of the patient vasiy be preserved for a 
number of years. The expectoration is generally copious, muco- or sero- 
purulent, rarely fetid. There is retraction of the affected side, displace- 
ment of the apex beat and lateral curvature of the spinal column. The 
unaffected side is enlarged. The intercostal spaces disappear, the ribs 
sometimes even overlapping. The tactile fremitus is generally increased, 
but if the pleural membrane is thickened the fremitus may be decreased. 
There is generally impairment of resonance. A tympanitic or amphoric 
note may be heard over a dilated bronchus. On the sound side the 
percussion note is generally hj^per-resonant. The breathing sounds may 
be feeble. They may be bronchial or cavernous, but rather amphoric. 
Late in the disease cardiac murmurs are not uncommon. 

Diagnosis. — This is never difficult. It is mainly to be distinguished 
from fibroid phthisis. In the latter both lungs are involved and there 



610 The Practice of Osteopathy 

is fever and bacilli are found in the sputum. An X-ray examination 
should be made. 

Prognosis. — The disease is exceedingly chronic and may last for 
many years. Death may result from gradual failure of the right heart, 
hemorrhage or from intercurrent attacks of acute pneumonia involving 
the other lung. 

Treatment. — Little can be done for this condition. Intercurrent 
bronchitis ma}^ be somewhat relieved by the treatment for chronic bron- 
chitis. The patient should dwell in a mild climate. Hygienic surround- 
ings and nutritious food are indicated. Something can be done by at- 
tempting to correct the condition of the ribs and vertebra?, but this 
measure, from the nature of the disease, is generally palhative at best. 

Congestion of the Lungs 

Congestion of the lungs may be active, passive or hypostatic. 
The two former have particular osteopathic significance, owing to the 
lesions involved. 

Active congestion may result from violent physical exertion, ex- 
cessive alcoholic indulgence, inhalation of hot air or as a symptom in 
pneumonia and other pulmonary affections. There is dyspnea and 
cough with rusty expectoration of a frothy nature. There may be ab- 
sence of fever. But generally a shght chill followed by moderate fever, 
pain in side, and cough are the principal sjnnptoms. On percussion, the 
note is dull with increased tactile fremitus and bilateral involvement. 

Prognosis is good under osteopathic treatment, but it must be 
promptly met as it is usually a symptom of another disease. 

Treatment is the same as in the beginning of pneumonia. 

Passive congestion, when not hj-postatic, is mechanical and due 
to an impeded return of blood to the left heart from mitral stenosis, or 
regurgitation, dilatation of the right ventricle and cerebral disease. The 
lungs are large with distended puknonary vessels with venous blood in the 
air spaces. There is dj^spnea and cough, with blood-streaked, frothj^ 
expectorations. 

The treatment is primarily of the condition causing the conges- 
tion, but in addition the upper ribs should be raised and thorough treat- 
ment of the abdomen and elevating the diaphragm are beneficial. 

Hypostatic congestion results from a weakened heart in exhaus- 
tion, infection or old age; also from continued dorsal decubitus. Rheu- 
matic fever, tuberculosis and other constitutional diseases, as well as or- 
ganic growths, may predispose. The condition gives rise to a mild form 



The Practice of Osteopathy 611 

of lobar pneumonia. Symptoms are not well defined and often are not 
recognized. There may be slight dullness, increased fremitus, moist 
rales and other signs of a venous engorgement. 

In treatment the first move is to change position of the patient 
and then look after any underl3dng cause. Osteopathically, follow treat- 
ment of pneumonia. In all cases of circulatory involvement of the lungs, 
treatment to relax muscles or to adjust vertebrae and rib lesions to the 
vasomotor nerves of the lungs is very efficacious. Landois (1904) says: 
"Irritation of sensory nerves, particularly if intense and long continued, 
causes a dilatation of the vessels in the areas innervated by them." 

Edema of the Lungs 

There are two forms of edema, collateral and general, which follow 
an intense congestion with transudation of serum into the air vesicles and 
interstitial tissue. The collateral form is locaHzed and usually appears 
in connection with pneumonia, pulmonary infarction or abscess. In 
general edema the base of the lung is involved to a greater extent, but 
the whole structure is affected and hydrothorax is generally present. 
The cause of edema is not well understood, but may result from a long 
Hne of constitutional diseases. The symptoms are dyspnea, cough with 
copious, blood-streaked sputum which is expelled with difficulty. There 
may be fever in the inflammatory type with weak, increased pulse. Dull- 
ness over the affected area, bronchovesicular breathing and small liquid 
rales are audible. The diagnosis must largely be made upon the bi- 
lateral dullness at the base of each lung and physical signs noted above. 
X-ray examination will usually be of value. Prognosis depends on the 
condition causing the edema and treatment should be directed to cor- 
recting it. Frequently edema is a terminal affection. This should be 
followed by osteopathic treatment to free the lungs of the effusion as out- 
lined under pneumonia, especially relaxation of the upper dorsal and cer- 
vical muscles, separation of the upper ribs and stimulation of the heart. 

DISEASES OF THE PLEURA 
Pleurisy 

Definition. — An inflammation of one or both pleural membranes. 

Varieties. — Etiologically, it may be divided into primary and 
secondary pleurisy; also, into acute and chronic pleurisy. Anatom- 
ically, the cases may be divided into dry pleurisy and pleurisy with ef- 
fusion (sero-fibrinous, purulent, hemorrhagic) . 



612 The Practice of Osteopathy 

Acute Pleurisy 

(Fibrinous or Plastic Pleurisy) 

The affection may be primary or secondary. As an independent 
affection it is rare. It may follow exposure to wet and cold or it may be 
due to mechanical injury. The disease may set in with pain in the side, 
slight fever and the friction sound of pleurisy may be present. These 
symptoms last a few days and then disappear and no exudation occurs. 
The pleural surfaces become more or less united. 

As a secondary process, dry plastic pleurisy arises from extension 
of the inflammation in acute or chronic diseases of the lung, especially 
pneumonia. Abscesses, gangrene and cancers are also causes. It some- 
times occurs in acute articular rheumatism, and in a large number of 
cases is associated with tuberculosis. This condition may be a com- 
phcation in chronic Bright's disease and in chronic alcohohsm. 

In the fibrinous form of pleurisy the serum is scant and the mem- 
brane is covered with a sheathing of Ijmiph, which finally organizes and 
adhesion takes place between the opposing surfaces. 

Serofibrinous Pleurisy 

This form is known as pleurisy with effusion. There is httle lymph, 
the exudate being mainly composed of serum. 

Osteopathic Etiology and Pathology. — Many cases rapidly fol- 
low exposure to cold, wet or an injury to the thorax. Exposure to cold is 
considered a mere predisposing agent, permitting the action of vario\is 
micro-organisms. The large majority of cases are due to tuberculous 
infection of the pleura. 

The osteopath finds that important predisposing causes of pleurisy 
are injury to the chest wall, ribs and vertebrse, and exposure to cold, 
causing contraction of the thoracic muscles. These injuries and strains 
throughout the chest result in an interference with the intercostal and 
phrenic nerves, and also with the intercostal and internal mammary 
arteries; consequently, there is produced a lowered vitality of the pleural 
tissues, which permits the attack of the micro-organisms. It may be 
secondary to rheumatism, Bright's disease, cancer and cirrhosis of the 
liver. 

Pathologically, there is an abundant exudation of serum. Fibrin 
is found on the pleura, and is rarely abundant in the serous fluid in the 
form of fioccuh. The fluid is straw colored as a rule. It varies greatly 
in quantity from one-half to four litres. Microscopically, there are 



The Practice of Osteopathy 613 

found leucocytes, red blood-corpuscles, shreds of fibrin and occasionally 
cholesterin, uric acid and sugar. The composition of the fluid resembles 
blood serum, and is rich in albmiiin. 

Various displacements of the adjacent organs are caused by the 
effusion. The lung is more or less compressed into the back part of the 
pleural sac. The heart is displaced. The diaphragm may be crowded 
downward. On the right side this lowers the liver; on the left it dis- 
places the stomach, transverse colon and sometimes the spleen. 

Symptoms. — The onset maj^ be abrupt with a chill, severe pain 
in the side and fever. With few exceptions the disease comes on insid- 
iously, pain in the side being the first symptom. The pain is sharp and 
cutting and is aggravated by breathing or coughing. There is moderate 
fever, the temperature ranging from 102 to 103 degrees F. Dyspnea 
may be present at the onset. This is due to the fever and pleuritic pain. 
When the fluid is effused slowly, dyspnea may be absent except on ex- 
ertion. It is most marked when the effusion has developed rapidly. 
As the effusion accumulates and the inflamed surfaces separate, the pain 
diminishes and, as a rule, soon disappears. 

Physical Signs. — Immobihty and bulging of the affected side, de- 
pending on the amount of exudation. The intercostal spaces are obht- 
erated. The apex beat of the heart is displaced. Upon palpation the 
limited movement of the chest is more accurately determined. Tactile 
fremitus is largely diminished. The position of the heart's impulse can 
be readily located by palpation. Displacements of the liver and spleen 
can be felt through the abdominal walls. At first the percussion notes 
are impaired and later there is dullness which gradually rises as the fluid 
increases. The upper line of dullness is not horizontal when the patient 
is in the erect posture, but is higher behind than in front. Above the 
effusion in the sub-clavicular region, percussion gives a tympanitic note, 
the so-called Skoda's resonance. In moderate effusions the level of 
dullness often changes with the position of the patient. Early in the 
disease a friction rub can usually be heard. As the fluid accumulates, 
the breath sounds become weak, distant and may have a tubular or bron- 
chial quahty. Vocal resonance is usually lessened. There may be 
bronchophony, or it may manifest a nasal or metallic quality, resembling 
somewhat the bleating of a goat (Lsennec's egophony). X-ray examina- 
tion should be made. 

Duration. — The course is extremely variable. The fever is due to 
inflammation and may last for two or three weeks, when it may subside. 
The cough and pain disappear and the effusion, which is usually slight in 



614 The Practice of Osteopathy 

these cases, may be absorbed quickly. In cases where the effusion is 
poured out rapidly it may be absorbed just as quickly. In cases where 
the effusion is poured out slowly or where the effusion reaches as high 
as the fourth rib, recovery is usually slower. Large effusions may per- 
sist without change for months and finally the case may become subacute 
or chronic. This is particularly true of tuberculous cases. 

Prognosis. — This depends largely upon the cause; on the whole, 
prognosis is favorable. Death is a rare termination of serofibrinous 
effusion; death may, however, occur suddenly without sufficient lesions 
to explain the cause. The exudate may become purulent. 

Treatment of Acute Pleurisy 

An early treatment and rest in bed with a liquid diet are the measures 
to be employed at the beginning of the attack. Pay particular atten- 
tion to any primary disease and to the general health. Rarely is there 
any difficulty in locating certain predisposing causes of the disturbance. 
Then often a rib or corresponding vertebra is badly subdislocated over 
the seat of the disease. The sympathetic and phrenic nerves are in- 
volved through the intercostal and phrenic nerves. A careful examina- 
tion of the side of the affected chest should be made, as there may be 
more or less obstruction of the intercostals and the internal mammary 
arteries from their branching of the aorta and subclavian vessels. A 
dislocation of the first or second rib may affect the subclavian vessels 
and their branches markedly ; although all the upper ribs and the thoracic 
muscles should be examined carefully for derangements which would 
affect these blood-vessels and produce an exudation. Ice-bags upon the 
chest, as in pneumonia, may be used. Limiting the movements of the 
chest with a bandage or adhesive strips will give considerable rehef . 

When the effusion has taken place, carefully raising and spreading 
the ribs with attention to special points of involvement, will at times 
cause absorption of the fluid. The daily amount of liquid food should 
be greatly lessened with a view of depleting the blood serum from var- 
ious tissues; thus the serum collecting in the pleura, which is a lymph 
space, will also be absorbed. Treatment of the bowels, kidneys and skin, 
so that they may be rendered active, will aid in the depletion of the 
blood serum. 

It may be necessary in some cases to aspirate, especially if other 
methods fail and if the effusion is large. The points of operation are in 
the mid-axillary line at the sixth interspace or at the angle of the scapula 
at the eighth interspace. In puncturing, the needle should be held close 



The Practice of Osteopathy 615 

to the margin of the upper rib so as to avoid the intercostal artery. With- 
draw the fluid slowly and if faintness is produced, desist. 

Empyema should be treated surgically. Simply tapping is rarely 
sufiicient. A free incision, as in abscess, and thorough drainage should 
be made. Care must be taken that the drainage tube is large enough. 

" In cases of pleurisy the axilla and the inner arm may be tender and 
painful; this is due to the pleuritic inflammation being carried by the 
way of the 'nerve of Wrisburg.' 

''The pleuritic pain in the costal muscles compels restricted move- 
ment of the ribs and also limits the respiratory function of the dia- 
phragm. These painful cramps and stitches are independent of the 
pain arising alone from the inflamed pleural surface, and the diminution 
of the respiratory movements is due to a particularly contractured state 
of the muscles of the chest as is demonstrated by the fact that the pa- 
tient can not draw a long breath; hence one may reasonably conclude 
that natm*e has so distributed nerves to the pleura as to enable that 
serous membrane to control the muscles which create movements of the 
adjacent costal surfaces and thus insure its quietude during the stages of 
inflammation or repair. " (Ranney) . 

Chronic Pleurisy 

Definition. — Chronic inflammation of the pleural layers. There 
are two forms, exudative and dry or plastic pleurisies. 

Chronic Pleurisy with Effusion. — This may follow an acute sero- 
fibrinous type. Some cases develop very slowly. In most cases in 
children, the fluid changes to pus early in the disease. The fluid may re- 
main for months without changing to a purulent character. In such 
cases the character and physical signs do not differ from those in acute 
serofibrinous pleurisy. 

Chronic Dry Pleurisy. — These cases originate in two ways : 

First, this may succeed pleural effusion when the fluid portion of 
the exudate is absorbed and the pleural layers are opposed. They are 
separated only by fibrinous elements that become organized into firm con- 
nective tissue. This process goes on at the base, principal^, which, if 
it follows the acute form, produces but shght flattening, but if it suc- 
ceeds the chronic form or empyema, the extent of retraction and flat- 
tening ^vill be marked. Calcification may occur in these firm, fibrous 
membranes and occasionally little pouches of fluid are found between the 
false bands. 



616 The Practice of Osteopathy 

Second, a large number of cases are dry from the onset. This con- 
dition msiy follow directly acute plastic pleurisy. It may be of tu- 
berculous origin or it may set in without any acute symptoms. No 
matter how shght the plastic exudate may be, it invariably tends to be- 
come organized, thus producing adhesion of the laj^ers. This is un- 
doubtedly the result when the pleurisy is primary or secondary. The 
adhesions are generally circumscribed. When the adhesions are of 
tuberculous origin they may be locally confined to one pleura or they may 
be bilateral. In these cases both the parietal and costal layers are thick- 
ened, and embodied in the thickened pleura are found firm fibrin masses 
and small tubercles. 

Occasionally, vasomotor sjTuptoms arise in chronic pleurisy, es- 
pecially in cases of tuberculous origin, and are probably due to the in- 
volvement of the first thoracic ganglion. These almost invariably mean 
that there is a displacement of the first, second, or third rib. Unilateral 
flushing or sweating of the face or dilatation of the pupil are frequentlj' 
noticeable. 

Symptoms. — Definite s3Tnptoms are rarely present. In some 
cases the physical signs are quite pronounced, while, on the other hand, 
they may be entirely negative. In mild cases there may be slight im- 
mobility of the affected side with feeble breath sounds. In other cases 
there may be very full chest expansion while the breath sounds are feeble. 
In a large number of instances the phj^sical signs are quite distinct. There 
is displacement of the viscera, retraction of the chest walls, curvature of 
the spinal column and dropping of the shoulders. There are feeble 
breathing and creaking, leathery friction sounds. Dullness is found at 
the base. 

Treatment. — The treatment of chronic pleurisy is largely that of 
acute pleuris.y. Gymnastic and methodical breathing exercises should 
be emploj-ed in helping to correct the thoracic walls. Care must be 
taken not to injure the chest and pleura if adhesions have formed. Sur- 
gical work maj^ be necessary in some cases. 

The vasomotor symptoms that are sometimes manifested in chronic 
pleurisj^ and are claimed to be due to involvement of the first thoracic 
ganghon, are an interesting feature to the osteopath. Such cases would 
probabl}^ present to the osteopath a marked lesion of the upper dorsal 
vertebrae or the second or third rib. These vasomotor symptoms are 
also found in pleurisj^ associated with tuberculosis of the apex of the 
lung. 



The Practice of Osteopathy 617 

The osteopath frequently treats these cases and he should be cau- 
tious about over treating or straining the chest wall. The adhesions are 
persistent and often there is more or less pain, so care must be exercised 
when attempting to structurally readjust. Do not expect to completely 
relieve every case, but nevertheless there are few cases but that can be 
benefited. Occasionally the pain alone is due simply to pleurodynia. 

DISEASES OF THE URINARY SYSTEM 

Diseases ©f the Kidneys 

(Renal Hyperemia) 

Definition. — An increase in the amount of blood to the vessels of 
the kidney. It is active hyperemia when there is arterial congestion, 
passive hyperemia when there is venous congestion. 

Osteopathic Etiology and Pathology. — Active hyperemia may 
be caused by injuries to the renal splanchnics, especially the tenth to 
twelfth dorsal segments; injuries over and to the kidneys; exposure to 
cold when the body is very warm; poison given, as diuretics; eruptive 
fevers and pregnancy, or follow genito-urinary operations. Passive 
hyperemia may be caused by obstructive diseases of the general circu- 
lation, as chronic heart, lung and liver diseases, or by pressure on the 
renal veins by tumors, growths and the pregnant uterus. Thrombosis 
of the renal veins may produce passive hyperemia, but rarely. 

Pathologically, in active hyperemia the kidney is swollen and 
shghtly enlarged. Upon removal of the capsule, the kidney is found to 
be brown and mottled. On section the parts bleed freely, the Malpigh- 
ian bodies are distended, and microscopical examination shows a cloudy 
swelling of the renal epithelium. In passive hyperemia the kidney is 
swollen, hard, firm and of a bluish red color. Later there is an over- 
growth of connective tissue and some infiltration between the tubules. 
The Malpighian bodies occasionally become shriveled and the renal 
epithehum fatty. 

Symptoms. — In active hyperemia the urine is scanty, of high 
specific gravity and of high color, containing some albumin and casts. 
Pain is experienced over the loins, following the course of the ureters, 
and the bladder is irritable. There are headache, nausea and vomiting. 
When from infection, fever may be present. 

In passive hyperemia the symptoms are primarily those caused 
by the disease producing the disorder. There is weight over the loins 
and dropsy. The urine is diminished, of high specific gravity, highly col- 
ored, albuminous and occasionally shows a few hyaline casts. 



618 The Practice of Osteopathy 

Prognosis. — Active hyperemia. — Usually favorable if it can be 
treated in time. If prolonged, acute nephritis may develop. Passive 
hyperemia. — Depends on the cause. If the disease is prolonged, it 
terminates in interstitial nephritis. 

Treatment. — Active hyperemia. — Absolute rest and thorough 
treatment to the renal splanchnics and treatment over the abdomen to 
the kidneys directly by carefully raising them. Adjust the lower ribs if 
found lesioned. Water should be drunk Uberally and the patient en- 
couraged to use vapor baths. Favorable hygienic surroundings, warmth 
and good food are indispensable. Warm applications over the loins are 
helpful. 

Passive hyperemia. — The treatment largely depends upon the 
cause, but too much importance cannot be given to the treating of the 
vasomotor fibers of the kidneys from the eighth dorsal to the first lum- 
bar. Textbooks state that the vasomotor fibers to the kidneys are from 
the ninth to the twelfth dorsal vertebrae, inclusive, but osteopathic ex- 
perience shows we can affect vasomotor fibers slightly higher. Treat- 
ment here has a distinct effect on the blood pressure within the glom- 
eruli. The renal epithelium is extremely sensitive to circulatory changes. 
Even the compression of a renal artery for only a few minutes causes 
marked disturbances. Hence any irritation or obstruction to the vaso- 
motor innervation of the renal blood-vessels may result in serious con- 
ditions. The superior cervical ganglion of the sympathetic and the 
sciatic center have important bearing on the secretions of the kidney, 
through vasomotor fibers. Due attention should be paid to the bowels, 
and the patient required to take plenty of rest and a light diet. 

Acute Parenchymatous Nephritis 

(Acute Bright's Disease) 

Dehnition. — An acute, inflammatory process affecting the epi- 
thelium of the uriniferous tubules and due to the action of cold or toxic 
agents upon the kidneys, as well as to injuries to the renal splanchnics; 
is characterized by certain nervous symptoms with fever, dropsy, and 
scanty and highly colored urine. This inflammation involves more or 
less the whole kidney. 

Osteopathic Etiology and Pathology. — This disease is caused 
by exposure to cold and wet while the body is warm and perspiring. 
Excessive use of alcohol may be a factor. May be caused also by in- 
fectious diseases, such as scarlet fever, diphtheria, measles, smallpox, 
acute tuberculosis and others; also by certain specific poisons which are 



The Pkactice of Osteopathy 619 

eliminated by the kidneys, as turpentine, chlorate of potash, carbolic 
acid, phosphorus, ginger, cantharides and oil of mustard; also by preg- 
nancy, as this is supposed to compress the renal veins, or through toxic 
agents. Syphilis may be an underlying cause. Blows and injuries to 
the back at the tenth, eleventh and twelfth dorsals are frequently the 
cause. Lesions are found from the sixth dorsal to the fourth lumbar. 
The lower three ribs may be at fault, while the innominate and muscu- 
lar contractions have been found to be pathological factors. Lordosis 
may be a contributing cause. Loudon places considerable importance 
on cervical lesions and McConnell beheves vasomotor disturbance plays 
an important causative role in the disease. 

Pathologically, at times the kidney alteration may be so sUght 
as not to be recognizable by the naked eye, the appearance varying ac- 
cording to the stage and severity of the disease. The kidneys become 
enlarged, engorged and of a bright red color, and later have a mottled 
appearance; and when the capsule, which is non-adherent, is stripped 
off, the kidne}^ is found to be soft and inelastic. In most of the cases in 
which the disease is due to toxic agents brought to the kidney through 
the blood-vessels, the glomeruU suffer first. The epithelium of the 
glomeruH and tubules is the seat of cloudy swelUng and, in the later 
stages, of fatty change and hyaline degeneration. The tubules are 
clogged by altered cells, leucocytes and blood-corpuscles. In mild cases 
the interstitial tissue is simply inflamed, but in all cases it becomes more 
or less mixed with leucocytes and red blood-corpuscles. Osteopathic 
lesions produced upon animals in the region of the ninth to the twelfth 
dorsal, resulted in acute nephritis. The autopsy findings were distinctly 
typical. 

Symptoms. — The onset is usually sudden, with moderate fever, 
pain in the back in the lumbar region and over the kidneys and follow- 
ing the ureters. Nausea and vomiting may be present. Dropsy soon 
appears, beginning with slight swelling or puffiness in the face below the 
eyes, later showing itself in edema of the abdominal walls and extremities. 
Uremic symptoms may develop. The urine is characteristic; is dimin- 
ished in quantity and of high specific gravity; at first the sediment is 
copious and reddish brown in color, becoming less in amount and of high 
color. This sediment contains casts of the uriniferous tubules, free 
l)lood, epithelial cells, uric acid and urates. There are large quantities 
of albumin in the urine. 

The presence of albuminous matter in the urine, even in large quan- 
tities, is not sufficient evidence to warrant a diagnosis of Bi-ight's disease 



620 The Practice of Osteopathy 

nor is the amount a guide as to the severity of the case, for grave condi- 
tions often show a slight amount (Loudon).^ 

Diagnosis. — The general symptoms may be very sUght, for the most 
severe cases may manifest shght edema of the feet, or there may be only 
the puffiness under the eyes and of the eyelids. In such cases the diag- 
nosis must depend upon examination of the urine. With previous his- 
tory, suddenness of the attack and character of the urine, ordinarily the 
diagnosis will be quite easy. 

Prognosis. — Although this disease is generally grave, the prognosis 
is favorable and the majority of cases recover under judicious treatment. 

Treatment. — Cases of acute nephritis require rest, quiet and 
warmth. Many cases recover under these conditions alone. It is abso- 
lutely necessary, however, that these conditions exist no matter what 
other treatment is used. A thorough treatment to the renal splanch- 
nics cannot be overestimated for it is here (tenth to twelfth dorsal, in- 
clusive) that a majority of the lesions producing acute nephritis occur. 
Besides correcting the vertebral and rib displacements in tliis region, a 
very effective treatment is to have the patient lie fiat upon the back and 
then the osteopath, reaching around the patient with the fingers of one 
hand on either side near the spines of the lower dorsal vertebree, raise 
the patient so that the entire body, except the shoulders and the feet, 
are hfted clear of the bed. Thus the treatment springs the spine anter- 
iorly and produces a m.arked effect upon the Iddneys through the renal 
vasomotor nerves. Occasionally lesions in the upper cervical region in- 
terfere with the normal activit}^ of the renal nerve fibers passing to the 
kidneys by way of the superior cervical ganghon of the sjrmpathetics. 

Another very effectual treatment for the kidneys is treating them 
through the abdomen by a careful pressure upon the kidneys through the 
abdomen on either side of the umbiUcus, thus lightly working each kid- 
ney outward and upward. Tliis treatment relaxes any tissues about the 
blood-vessels, nerves and lymphatics to and from the Iddneys that may 
be contracted and thus aids in establishing a normal activity of the in- 
volved organs. It also helps in i*elaxing tissues about the ureters and 
prevents the clogging up of the latter with debris. Bandel and Stearns 
report cases in which an impacted colon was an important factor in this 
particular. 

The above means have for their object the direct reUef of the con- 
gestion of the kidney. This is further aided by keeping the bowels 
active, which supplements the action of the kidneys, and by increasing 

1. Journal of the American Osteopathic Association, Jul3% 1904. 



The Practice of Osteopathy 621 

the activity of the skin. This also aids in reheving dropsical effusions. 
The hot pack, in which the patient is wrapped in a wet sheet and then 
covered by a number of blankets, is an exceedingly good method to re- 
lieve the kidneys of some of the work and lessen their congestion, be- 
sides arresting uremic intoxication. This can be repeated daily if neces- 
sary. Where there is dropsy and scanty urine, the indications are to in- 
crease the secreting action of the kidney; besides treatment through the 
renal splanchnics, which contain the vasomotor nerves of the kidneys, 
stimulating treatment to the vagi will help to increase the urinary se- 
cretion. Hot fomentations, placed directlj^ over the region of the renal 
splanchnics, is a valuable aid in cases which do not respond quickly to 
osteopathic stimulation. Treatment of the liver is important. Injec- 
tions of cold water into the intestines will tend to stimulate the secretion 
of the kidneys, but this should be used with the greatest caution ; in some 
cases tepid water would be better (see uremia). 

The diet of the patient with acute nephritis is important. Give 
food that is easy of digestion and which contains a minimum amount of 
nitrogen. The stomach is quite likely to be irritable, consequently food 
that is adapted to it should be selected. Milk and weak animal broths 
are undoubtedly the best foods. The return to a solid diet, especially 
of meat, should be very slow. Suitable adjuvants to the milk diet are 
rice and farinaceous preparations. Loudon^ recommends complete 
withdrawal of all foods for twenty-four to fortj^-eight hours and the re- 
ducing of nitrogenous foods to a minimum; a diet of milk and cream after 
the fast, followed by cereals and broths, then eggs and fish until albumin 
disappears from the urine. Alkahne mineral waters are useful to help 
maintain an alkaline urine, thus tending to withdraw exudates. The 
patient should be treated daily at first and later on every other day, for 
case reports show frequent treatments hasten recovery. 

For treatment of acute uremia in Bright's disease, see uremia. 
Complications should be treated as affections independent of the renal 
disorder. 

Chronic Parenchymatous Nephritis 

Dehnition. — A chronic inflammation of the Iddney, involving the 
epithelium, glomeruli and interstitial tissue, characterized by dropsy, 
increasing anemia, albuminous urine and acute uremia. 

Osteopathic Etiology and Pathology. — It may be the result of 
acute nephritis. It follows the same diseases as already mentioned in 

1. .Journal of the American Osteopathic Association, Dec, 1904. 



622 The Practice of Osteopathy 

acute nephritis. More often it follows the same diseases as already men- 
tioned in the acute form, syphilis, tuberculosis, purulent conditions, 
focal infections (streptococcus), alcohol, scarlatina and pregnancy con- 
tributing the greater number. It is more common in the male sex and 
in early adult life. Habitual exposure to cold and dampness; chronic 
lesions of the spine, chiefly in the lower dorsal region, are causative fac- 
tors. 

Pathologically, the large white or a yellowish white kidney 
is the most common kidney lesion. In this form the kidney is enlarged, 
often to twice its normal size, is smooth, and the capsule very thin. The 
tubes, on microscopic examination, are found to be choked with broken- 
down granulated epithehum and fibrinous casts. The capillaries show 
hyaline changes. The interstitial tissue is increased everywhere, but 
not to an extreme degree. Catarrhal swelling and hyperemia (to a 
slight degree) are found in the pelvis of the kidne^^ 

In the second stage — that of the small white kidney — there is a 
reduction in the size of the organ, due to the destruction of the renal 
epithelium and the contraction of the overgrown connective tissue. 
Some hold that this may be a primary, independent form and not always 
preceded by the large white kidney. The organ is pale in color, rough 
and granular, the capsule being thickened and somewhat adherent. There 
is an accumulation of fatty epithelium in the convoluted tubules, con- 
stituting marked areas of fatty degeneration and giving the organ a 
white or whitish yeUow appearance. It is this which gives the name of 
small granular fatty kidney to this form. There are extensive inter- 
stitial changes, degeneration of tubules and destruction of great numbers 
of the glomeruli. 

Chronic hemorrhagic nephritis is a variety associated with 
this stage. The organ is enlarged, and scattered throughout the cortex 
are found brown hemorrhagic foci due to hemorrhages into and about 
the tubes. Otherwise the changes are similar with those found in the 
first form. 

Symptoms. — It usually begins as a chronic affection and the symp- 
toms slowly become apparent. FaiHng health and loss of strength, dys- 
pepsia and anemia, waxy appearance with puffiness of the face, dropsy 
and increased arterial tension with hypertrophy of the left ventricle, 
gradually make their appearance. Uremic symptoms are common, 
while dropsy is marked and persistent. Vomiting and sometimes pro- 
fuse diarrhea occur; in fatal cases there is sometimes found to be ulcera- 
tion of the colon. The urine, as a rule, is diminished in quantity, is 



The Peactice of Osteopathy 623 

often veiy scanty, although it is frequently normal in color and appear- 
ance. There is an abundance of albumin, heavy sediment, hyahne and 
granular tube casts, epithelium from the kidneys and pelvis, leuko- 
cytes and often red blood-corpuscles. If fatty degeneration takes 
place, there will be fatty casts and oil globules. In the later stages the 
urine is abundant, low specific gravity, considerable albumin, and manj^ 
casts. 

Diagnosis. — In the inflammatory stage, where there is enlargement 
of the kidney, extreme pallor, scanty urine, albumin, and tube casts, 
history of infections, pregnancy, or exposure to cold and wet, and lesions 
in the lower dorsal region, the diagnosis is clear. 

Prognosis. — Always give a guarded prognosis; relapses are frequent, 
but cases have been cured. There is alwaj^s a tendency for the sub- 
chronic forms to become chronic. 

Treatment. — The treatment requires persistent work, especially 
over the renal splanchnics, and strict attention on the part of the pa- 
tient to hygienic principles. The lower dorsal lesions are very apt to 
be refractory owing to extensive fibrotic changes of the deep muscles 
and capsular ligaments. But repeated effort will usuallj^ secure results. 
Care should be taken as to exposure to cold and overexertion. The qual- 
ity of the blood should be improved, as it is anemic and contains various 
toxic products. Strict attention should be paid to the diet. Iron is 
largely used for anemic conditions, but this principle we hold to be wrong. 
It is not more iron that is wanted, but an abihty of the system to assimi- 
late the iron which it has. Relative to diuretics von Noorden says: 
"It would be the greatest paradox to economize the renal work to the 
utmost in one direction (diet, sweating, etc.) and on the other hand ex- 
cite them to increased activity by means of the strongest stimulants we 
possess, (drugs). I regard such prescribing as radically wrong." The 
diet should be carefully selected and of minimum amount. The pure 
milk diet is undoubtedly the best. The use of meat seems to favor uremic 
convulsions. 

The digestive organs should be kept in as good condition as pos- 
sible, particular attention being paid to the liver and bowels. The use 
of suitable clothing is important; wool should be worn next to the body. 
The skin is a powerful adjuvant to kidney chmination, and the sup- 
pression of the action of the skin throws extra work on the kidneys. 
Possibl}'- stimulation of the lung function would aid in the elimination. 
Rest, '\\itli a |)roper amount of fr(>sl) air nnd out-door exercise, is essen- 
tial. 



624 The Practice of Osteopathy 

In conditions calling for attention to the skin and bowels the treat- 
ment will be the same as in acute parenchjTQatous nephritis. There 
is a ganghon on each side of the umbilicus within a radius of an inch that 
sends fibers to the kidneys (Dr. Still). Just what is the function of these 
gangha is unknown. The treatment of the compHcations is independent 
of that for the renal trouble. For direct treatment to the kidneys see 
acute Bright's disease. 

Interstitial Nephritis 

Definition. — A chronic inflammation of the kidney in which there 
is reduction in its size due to an extensive destruction of the tubular sub- 
stance, with an overgrowth, and later a contraction, of the connective 
tissue elements. Cardio-vascular changes, arteriosclerosis and cardiac 
hypertrophy are usualh' associated. 

Osteopatliic Etiology and Patliology. — Osteopathic lesions to 
the renal splanchnics are important predisposing causes. The disease 
may follow parenchymatous nephritis; or it may be caused by a con- 
tinued passive congestion due to valvular heart disease. Gout; cystitis 
(often following gonorrhea), the inflammation extending up the ureters 
to the kidney; heredity; old age; long continued worry, anxiety or grief; 
chronic alcoholism, overeating; syphiHs; tuberculosis; focal infections, 
especially of streptococci; chronic mineral poisoning (as from lead), and al- 
terations in the renal ganghonic centers are causes. It chiefly occurs in 
males during middle hfe. 

Pathologically, both kidneys are involved (although one may be 
more affected than the other), and reduced in size, often to less than half 
their normal size. After removing the capsule, which is thickened and 
adherent, the surface is found to be uneven, or granular and containing 
small cysts. The kidney is hard, tough and resistant, the color varying 
from a darkish brown to a 3"ellowish gray. The cortical portion is es- 
pecially reduced in size. On microscopic examination, the connective 
tissue appears greatly increased; this contracts, compressing the tubules 
and blood-vessels, causing their destruction. There is general arterial 
sclerosis, and the left side of the heart is hypertrophied. There are 
frequent nasal and retinal hemorrhages, due to the brittleness of the 
arterial walls which predispose them to rupture; hence, apoplexy is a 
frequent termination. The ganglionic centers, being interfered with, 
undergo fatty degeneration and atrophy. There are marked retinal 
changes— retinitis, fatty degeneration of the retinal tissues and sclerosis 
of the nerve fiber lavers. 



The Peactice of Osteopathy 625 

Symptoms. — The onset is insidious. In most cases the symptoms 
are latent. The general health is disturbed; there are frequent mic- 
turition, gastric disturbances, tense and bounding pulse, hypertrophy of 
the left ventricle, high blood pressure, disorders of vision, sleeplessness, 
headache, furred tongue, slight swelhng of the feet, dry skin, scurvy and 
shortness of breath. The urine is increased in quantity, of acid reaction, 
Hght in color, low specific gravity, with a small amount of albumin, a 
few hyahne casts, and some epithelial cells. There is increased thirst 
and the patient m.ay have to urinate two or three times during the night. 
There is well marked mucous cloud, shght sediment, and as the disease 
advances the urine may be diminished, the albumin increased and the 
casts become more numerous, while occasionally blood-cells will be 
found. 

Much importance should be attached to the blood pressure condi- 
tion. 

Diagnosis. — The early stages are not always recognizable. Later, 
while there is high arterial tension, thickening of the arterial walls and 
marked hypertrophy of the heart, the urine should be examined very 
carefully both night and morning, as the diagnosis will greatly depend 
upon the condition of the urine, which is increased in quantity, of low 
specific gravity, with a trace of albumin, narrow hyahne and pale gran- 
ular casts, making the diagnosis usually easy. 

Prognosis. — It is generally incurable, but favorable so far as the 
power to prolong hfe is concerned, provided the diagnosis be made early 
in the case, and the patient lives a quiet hfe. The case usually termi- 
nates with convulsions, coma and death. Apoplexy is frequently asso- 
ciated with chronic nephritis. In all forms of chronic nephritis some 
intercurrent infectious disease is quite possible, which is apt to be serious 
owing to the cachectic state. 

Treatment. — The dietetic and hygienic treatment is the same as 
in chronic parenchymatous nephritis. The nerve and vascular supply 
to the kidneys should be treated as in acute parenchymatous nephritis. 
Freedom from worry and overwork, and if possible change of chmate, 
should be prescribed. Frequent bathing, with friction of the skin, should 
be insisted upon and the bowels kept regular by a treatment of alkahne 
water. In all kidney cases special attention should be given the Uver. 
The alkaline water is a good diuretic; besides it flushes the kidneys and 
lu'lps to remove the debris. 

These cases invariably present a rigid spine which should be care- 
fully but thoroughly treated, traction being one of the methods that give 



626 The Practice of Osteopathy 

comparatively quick and excellent results. Overcoming spinal immo- 
bility, correction of the dorsal area, attention to the chest rigidness, and 
frequently raising the abdominal organs will often considerably reduce 
the blood pressure. 

The accidents and compUcations which so often endanger the pa- 
tient, must be treated as they arise. 

Amyloid Kidney 

Definition. — A pathological state of the kidney in which there is a 
peculiar infiltration into the kidney structure of an albuminoid material 
of a waxy appearance. 

Etiology and Pathology. — This is associated with Bright's dis- 
ease and other wasting diseases. It is most frequently caused by pro- 
fuse and long continued suppuration, especially of the bones, by syphilis, 
tuberculosis, cancer, lead poisoning and gout. 

Pathologically, the kidney is large and pale, but it may be normal 
in size or even small, pale and granular. The capsule is not adherent, 
the surface of the kidney, after removing the capsule, is pale and anemic. 
On section the cortex is seen to be enlarged. It is homogenous, anemic, 
pale, waxy and resisting. On microscopic examination there is found to 
be an infiltration of a homogeneous or wax-hke material. This pro- 
gresses until all parts of the organ are infiltrated. As the result of this 
pressure the structures of the kidney undergo an atrophic degeneration, 
the kidney becoming contracted, smaller, rough and even distorted in 
shape. The cortex becomes narrowed and the capsule adherent. If a 
section of an amyloid kidney be stained with a solution of iodine, num- 
erous mahogany red points appear. 

Symptoms. — There are similar changes in the liver, spleen and often 
the intestinal canal. There is a profuse, watery diarrhea, due to amyloid 
changes in the intestinal canal, with loss of flesh and strength, edema of 
the lower extremities, and ascites. There is an increased flow of pale, 
watery mine, of low specific gravity; albumin is abundant and usually 
hyaline, often fatty or finallj^ granular tube casts occur. 

Prognosis. — As a rule the prognosis is decidedly unfavorable and 
it must be controlled by the disease with which it is associated. 

Treatment. — The primary disease demands attention, otherwise 
the measures of treatment indicated are those of chronic parenchymatous 
nephritis, with special attention to the general health and surroundings 
of the patient. Give a generous diet and be persistent with the treat- 
ment. 



The Practice of Osteopathy 627 



Pyelitis 



Pyelitis is inflammation of the pelvis of the kidney. When a suppu- 
rative inflammation extends into the interstitial tissue of the organ, it 
produces a condition called pyelonephritis. The inflammation usually 
starts in the pelvis of the kidney, the infection being carried there either 
by the circulation or the urinary tract, but it soon involves the rest of 
the kidney. PyeUtis is usually secondary to some other conditions such 
as urethritis, cystitis, or ureteritis. "Infection of the kidney rarely takes 
place through the blood and only when the vital membrane of the kidney 
is impaired." It may start from within the organ in the interstitial 
tissue, caused by infectious embohsm or traumatism, or the tubules may 
become obstructed by concretions. 

Osteopathic Etiology and Pathology. — Retained decomposed 
urine due to pressure upon the ureters by tumors or bladder disease; 
calculus concretion, kinked ureter, displaced kidney, traumatic agencies, 
as falls, blows, strains, kicks or penetrating wounds; nephritis, pregnancy, 
cold and wet, are causes. Pyehtis may follow cystitis, the inflammation 
extending up the ureters to the pelvis of the kidney and thence to the 
substance of the organ, inducing pyelonephritis. Tuberculosis, focal 
infections, and intestinal disorders (colon bacillus), are other causes. 
Lesions from the ninth dorsal to second lumbar or lower, and malnutri- 
tion are predisposing factors. 

Pathologically, the mucous membrane of the pelvis is usually the 
first affected, the inflammation generally extending from below upward. 
It is swollen and sometimes visibly congested and of a gray color. The 
pelvis and calyces are more or less dilated, while the papillae are flattened. 
There is a gradual dilatation of the calyces and atrophy of the kidney 
substance, until the whole organ may be converted into a pus sac. If 
complete obstruction occurs, the fluid portion maj^ be absorbed and the 
pus become inspissated and cheesy. The ureter is often dilated. In 
tuberculous pyelitis the apices of the pyramids are also invaded, the kid- 
ney substance is broken down and the result is the same. In the pyehtis 
caused by cystitis, the infection passes up the tubules or is carried by 
the lymphatics. The abscesses extend along the pyramids, burst through 
the papillse and calyx into the pelvis of the kidney, and thus also the 
kidney becomes a purulent sac. 

Symptoms. — Pain and tenderness over the region of the kidney 
first appear. In a few cases cystitis will be the only symptom. The sup- 
purative stage is marked by high fever and a chill or a succession of 



628 The Practice of Osteopathy 

chills. The general condition of the patient denotes prolonged suppura- 
tion. There is failure of health and more or less wasting and anemia. 
The urine is characteristic, contains pus, which varies in quantity greatly, 
and where only one kidney is affected, may be suppressed for a time and 
there will be a sudden outflow of the pus, due to the breaking of the sac. 
Blood is also very constant, but hardly ever of suflacient quantity to be 
seen by the naked eye. The urine is usually diminished in quantity and 
the color pale; the specific gravity is low on account of the small amount 
of urea present. The reaction of the urine is acid. Pus and blood render 
the urine slighth^ albuminous. Casts from the kidney, and even por- 
tions of the kidney, may be present. 

Diagnosis. — From nephritis by the absence of much albumin, 
tube casts and dropsy. From cystitis, by the history, lumbar pains and 
acid urine, in cystitis the urine is always alkaline. From perl- 
nephritic abscess, by the absence of edema over the lumbar region. 
The urine may be normal and there are lumbar pains and hectic fever. 
In tuberculous pyelitis there is a history of tuberculosis in other or- 
gans and there arc tubercles in the urine. Malaria or typhoid may be 
suspected. The X-ray and cystoscope should be employed. An ex- 
ploratory^ incision may be necessary. 

Prognosis. — Depends altogether on the cause and extent of kidney 
involvement. In simple cases and some tubercular, recovery may occur, 
although there is a tendency in all cases for the disease to become chronic. 

Treatment. — Depends upon the cause, but thorough treatment 
along the lower dorsal, the lumbar and sacral regions will be of consider- 
able benefit in controlling the catarrhal process in the kidney, its pelvis, 
the ureter and the bladder. If pathology permits, gently raising the 
kidneys, ureters and neighboring organs, knee-chest position, will ma- 
terially assist circulation and drainage. Fresh spring waters for dihients 
and restricting the diet to light food, preferably milk, are indicated. 
Rest is important and warm applications locally are sometimes helpful. 
The general health must be carefully watched as there is always consid- 
erable drain upon the system. A timely operation may materially 
lengthen the life in many cases. Attention to the bladder, urethra and 
prostate is necessary. 

Uremia 

The name applied to a series of manifestations resulting from the 
retention of poisonous materials in the blood, which should have been 
removed by the kidneys. Uremic symptoms may occur any time dur- 



The Practice of Osteopathy 629 

ing an attack of nephritis. In chronic cases it seems likely that extensive 
destruction of renal tissue is the principal factor that leads to the toxemia. 
They may also occur when the circulation of the blood in the kidneys is 
interfered with or the ureters are obstructed. They are not due alone 
to the urea (which is found to be increased in the blood), but more prob- 
ably several poisons that are retained in the blood. Traube's theory is 
that acute cerebral edema with anemia accounts for the symptoms. Hal- 
bert says: "A more recent and more plausible claim is to the effect that 
a poison is developed in the body as the result of nephritis, " for retention 
of effete matter or ligation of renal arteries and ureters or impaired renal 
activity does not fully explain the cause of the stupor, coma, convul- 
sions, sometimes paralysis, and gastro-intestinal disorders. 

Symptoms. — Loss of appetite, nausea, vomiting, headache and 
drowsiness are the initial symptoms. Headache is usually at the back 
of the head and may extend down the neck. The next symptom is coma, 
alternating with convulsions which may range from only a slight twitch- 
ing to Adolent epileptiform spasms. These spasms may occur without 
the slightest warning and are often followed by blindness which may 
last for several days. These attacks of coma and convulsions are some- 
times ascribed to localized edema of the brain. 

Transient paralysis is also due to congestion or edema of the brain 
and it may be of the cord. There may be mania which comes on ab- 
ruptly, although the delirium is not at all violent, while profound melan- 
cholia may be found. There may be nervous symptoms develop, such 
as numbness in the hands and fingers, itching of the skin and cramps in 
the muscles — especially those of calves of the legs. Pulmonary symptoms 
are sometimes continuous — dyspnea, paroxysmal dyspnea and Cheyne- 
Stokes' breathing. These attacks of dyspnea may be as distressing as 
true asthma. Cheyne-Stokes' breathing may be present without coma. 

Uncontrollable vomiting may set in with great abruptness, followed 
by hiccough and purging. There may be a catarrhal or diphtheritic in- 
flammation of the colon with diarrhea. The breath has a urinous odor 
and the tongue is often very foul. The pulse is slow and full, with a tem- 
perature below the normal, although during convulsions the pulse may 
become rapid and the temperature rise. Occasionally there are atypical 
forms of uremia which may be very confusing and obscure. 

Diagnosis. — The history, subnormal temperature, the urinous 
odor of the breath, high arterial tension and increased second sound of 
the heart will distinguish the condition. Feeling of numbness, palpi- 
tation, headache, restlessness, mental wandering are not infrequently 



630 The Practice of Osteopathy 

early symptoms. The phenolsulphonephthalein test for the secreting 
power of the kidne}^, and the examination of the urea in the blood are 
of great aid in diagnosis. 

Prognosis. — Extremely grave, but one should always be very 
careful in his prognosis, for there is a possibility of recovery, even after 
the most serious symptoms have been manifested. 

Treatment. — As impermeability of the kidneys prod\ices uremia, 
by not allowing the various poisons to be eliminated by the renal path 
as they should be, the treatment must be applied directly to the kidneys. 
Elimination is demanded and if treatment through the abdomen to the 
kidneys directly and to the i-enal splanchnics does not bring about prompt 
and thorough elimination of the intoxicating properties, the bowels and 
skin must be made active. The vapor or hot-air bath or hot pack should 
at once be used. An ice-bag to the head will be beneficial. An increase 
in the quantity of urine may be brought about by the displacement of a 
part of the mass of blood, which is in relative stagnation in certain parts 
of the vascular system. Forcing it into the main circulation in order 
to increase the pressure within the vessels of the kidney, is the treatment 
indicated. This great stagnant mass of blood is found in the arterial 
capillaries of the portal system in the fiver and splenic tissues and should 
be manipulated into the general circulation in order to increase the ar- 
terial tension of the kidneys and thus favor efimination. The treat- 
ment should mainly be applied to the vasomotor nerves of the portal 
system, from the fifth to the ninth dorsal, and directly over the 
abdomen, liver and spleen. 

The introduction of water, from 110 degrees to 120 degrees, or even 
150 degrees, into the colon by means of injections, is useful; warm irri- 
gations increase renal secretion, bowel action and sweating with a de- 
crease of tension. Cold drinks will stimulate the abdominal vessels and 
induce absorption of a certain quantity of water to still further increase 
diuresis. Cold irrigation increases blood pressure temporarily, but later 
it lessens the pressure; it should be used only with great caution. Milk 
is one of the best drinks to be used. Secretions of the liver must not 
accumulate. The bile must be expelled so that its toxicity will not be 
added to the other poisons. 

The food of the patient is an important matter. A milk diet is best ; 
avoid meat and nitrogenous foods and any food that leaves much resi- 
due. In this way the nutrition of the patient is kept up with a minimum 
of urea formation and, besides, there will be very little intestinal putre- 
faction. Emergency measures not mentioned above are repeated high 



The Practice of Osteopathy 631 

normal salt enemata (two to three pints), the alcohol sweat and vene- 
section (about one pint). When the attack is broken the condition re- 
solves itself into the renal disorder, generally acute Bright's disease. 

This disease illustrates one phase of the uselessness of drugs; for 
when the impermeabihty of the kidney has become such that it ceases to 
have the power of eliminating toxic substances formed by the organism, 
there is then retained the medicinal substances. The kidney is as im- 
permeable for therapeutic poisons as for the natural poisons and the em- 
ployment of toxic medicines in such cases has often no other effect than 
to bring an association of medicinal intoxication with an uremic. 

Renal Calculus 

Renal calculi are concretions formed by precipitation of sohds de- 
rived from the urine, and are found in the kidney or its pelvis. If large, 
they are called stones; the smaller masses are known as gravel or sand, 
according to their size. When the stones attempt to pass through the 
ureters, it brings on an attack of renal colic ; rairely are they voided with- 
out this symptom. 

Osteopathic Etiology and Pathology. — The affection occurs at 
all ages, more commonly, however, in children and in old people. The 
male sex is more liable than the female. Sedentary habits,' gout and 
excessive meat eating are predisposing causes. Heredity seems to be a 
predisposing cause in some famihes. Inflammation of the pelvis of the 
kidney, caused by derangement of the ribs and vertebra of the tenth, 
eleventh and twelfth dorsals or first lumbar, is an important etiological 
factor. 

Pathologically, the chemical varieties are : 

(1) Uric acid and urates are the most common. The stones are 
usually smooth or lobulated; are hard and of a reddish color. Usually 
in these stones, both uric acid and urates are to be found. This mater- 
ial may be passed in the form of sand or large stones. The sediment in 
the urine may be the nuclei of the stones; as may foreign matters, such 
as the mucus or desquamated epithelium caused by the inflammation of 
the pelvis of the kidney, blood clots, or, in fact, any foreign matter that 
may reach the urinary passages. Individuals passing a small amount 
of urine, and old people are the principal subjects. "As a consequence of 
concentration and high acidity of the urine, the uric acid and urates are 
readily separated in solid form and held together by the albuminous 
matrix." 

(2) Phosphatic Calculi -aw wliilc in color, soft and mortarlike. 



632 The Practice of Osteopathy 

They are composed of phosphate of lime, ammonia and magnesium phos- 
phate. These are found more often in the bladder than the kidnej'. 
Disease of the bladder is the cause. 

(3) Oxalate of Lime are a mixture of oxalate of lime and uric 
acid. They are dark in color, very hard and uneven, with hard, pointed 
projections. On account of their uneven shape they have been named 
mulberry calculi. These stones produce great pain as they pass through 
the ureters. 

There are other concretions of rare occurrence. 

Symptoms. — There is pain in the back in the region of the kidneys 
with more or less tenderness. The pain may be severe and paroxysmal. 
There may be bleeding, which is seldom profuse; this will give the urine 
a smoky hue, but may be present to such a small degree as to be only ap- 
parent b}^ the use of the microscope. The stone may obstruct the ureter 
and cause pyonephrosis or hydronephrosis. Pyehtis of a catarrhal 
character is common. In pyelitis there may be intermittent fever of 
several degrees, then sweating. There may or may not be pus in the 
urine. 

Renal Colic is caused when the calculus attempts to pass through 
the ureter so that ureteral spasms result. The stone, however, may be- 
come lodged at the entrance to the ureter. There is a sudden onset and 
great pain which starts in the back, radiating downward into the groin, 
down the side of the thigh and into the testicle and glans penis. The tes- 
ticle is often retracted, the face pale, the features pinched, and there is 
frequently vomiting. There are cold sweats and the pulse is weak. The 
paroxysm may last only a few minutes or extend over several hours. If 
uric acid is found, it points to uric acid or oxalate of lime calculi and the 
urine is acid in reaction. If alkaline phosphatic stones may be suspected, 
examination of the urine directly after the attack aids greatly in diag- 
nosis, for at other times the urine is usually negative. 

Diagnosis. — Biliary Colic. — The jaundice in bihary coHc comes on 
vevy soon after the obstruction begins. The stools are without bile and 
the pain extends from the right hypochondriac region to the upper ab- 
domen and the right shoulder. The urine is negative and a stone may be 
passed in the stools. Renal colic is often simulated when the ureter is 
obstructed from any cause whatever. It max be compressed from a 
floating kidney or tumor, or obstructed by a clot of blood, fragments of 
hj^datid cysts or plugs of mucus. Lumbo-abdominal neuralgia, 
intestinal colic, and renal tuberculosis may simulate renal coUc. 
The X-ray plate is of decided value. 



The Practice of Osteopathy 633 

Prognosis. — As complications may arise, it is best to give a guarded 
prognosis, but the prognosis is generally favorable. It is a disease that 
is very apt to recur when strains or falls affect the innervation to the 
kidney, but many cases have been permanently cured. If the stone is 
large, its passage along the ureter may prove fatal unless surgical inter- 
ference is instituted at once, but if it is renal sand it may be easily voided 
in the urine and thus the prognosis will be favorable. 

Treatment. — Treatment should be given toward overcoming 
the cause producing the calculi, which will often be found at the tenth 
rib. Treat the kidneys thoroughly, both through the renal splanch- 
nics and directly through the abdomen, anteriorly. But direct ab- 
dominal treatment should be given very cautiously. Treatment here 
corrects disorders and seems to release some solvent that acts upon the 
various forms of calculi and disintegrates the ones already formed and 
prevents the formation of others. Possibly this solvent is an internal 
secretion of some gland; possibly Hke the splenic secretion is to the bil- 
iary calcuh (Dr. Still.). Dr. Still held that one of the functions of the 
suprarenal capsule was to prevent the formation of these concretions. 

In the uric acid tendency, the free use of alkaline mineral waters 
for the solution of uric acid may be helpful. Much may be done by 
dieting. The amount of nitrogenous food should be limited, eating a- 
minimum amount of meat and using plenty of milk and vegetables. 
In the phosphatic tendency, diluted drinks freely used are helpful. 
Meats are indicated. Milk and vegetables should not be used freely as 
they tend to make the urine alkaHne. In all instances care of the gen- 
eral health and avoidance of beer drinking and excessive meat eating are 
demanded. 

During an attack of renal colic, when a stone had lodged in a ureter, 
one may be able, by very careful manipulation, to aid the stone in its 
progress downward, (somewhat after the manner of manipulating gall- 
stones), but do not delay surgical measures too long. By inhibiting the 
nerve force of the spinal nerves along the lumbar and sacral regions 
(chiefly tenth dorsal and first lumbar), relief may be given. The nerves 
of the ureters are derived from the inferior mesenteric, spermatic and 
pelvic plexuses. Emploj^ the hot bath; this may relax the spastic condi- 
tion. Cloths wrung out of hot water and appKed locally are of aid. 
Occasionally a change of posture will give relief. Even inversion of the 
patient is sometimes followed by immediate cessation of the pain. The 
patient may drink freely of hot lemonade or water. An anesthetic may 
bo of aid in the manipulation of a renal calculus in the ureter, as the 



634 The Practice of Osteopathy 

anesthetic will relax the tissues over the abdomen, making it much easier 
for one to get near the impacted calculus, but be cautious. Morphine 
may be necessary. During the intervals the patient should lead a quiet 
life and avoid sudden exertions of any kind. It is important to keep the 
urine abundant, consequently have the patient drink a large quantity 
of distilled water. "Renal calculus is brought about by lesions af- 
fecting the suprarenal capsule of the kidne}^, or spinal lesions from the 
tenth dorsal to the first lumbar, affecting the lower ribs." 

Movable Kidney 

This means a distinctly mobile condition of the kidney (ahnost 
always acquired, but may be congenital), due to the lax condition of the 
tissues which support it and to the elongation of the renal vessels which 
allow the kidney to move in certain directions. Rapid loss of tissue 
that absorbs the fat surrounding the kidney is a cause. There are al- 
most invariably lesions in the dorso-lumbar region that predispose to 
an abnormal mobility of the kidney. These lesions undoubtedly weaken 
the innervation to the surrounding and supporting kidney structures. 
A posterior spine, with consequent downward and constricting displace- 
ment of the floating ribs, is common, although lateral and anterior spines 
(dorso-lumbar region) may be found. Strains, heavy hfting, and var- 
ious violent exertions are important exciting factors. Tight lacing, 
pregnancies, an enlarged liver and gastro- and enteroptosis are also im- 
portant factors. This condition is found more commonly in women, 
and undoubtedly is a frequent cause of direct, gastro-intestinal, reflex, 
and obscure disturbances. There are very different degrees of mobihty 
in different cases. It may be so slight as hardly to be recognized or so 
great that it can easily be felt by the hand through the abdominal walls, 
resembling a movable tumor in the abdomen. 

Symptoms. — Often there are no noticeable sj^mptoms. Sometimes 
when the displacement and mobihty of the kidney are most marked, the 
reflex symptoms are not noticeable. The right Iddney is the one usually 
affected, on account of its relation to the Hvcr which moves during the 
respiratory act. Usuall}^ there is pain in the lumbar region and the pa- 
tient experiences a heavy, dragging pain in the abdomen, which especially 
manifests itself while standing and walking. There may be intercostal 
neuralgia. Various colicky and other gastro-intestinal pains, and ner- 
vous symptoms as neuresthenia, melancholia, hysteria and headache 
are common. There may be obstinate indigestion, palpitation of the 
heart, flatulence and cardialgia; also, an irritable bladder, due to pressure. 



The Practice of Osteopathy 635 

At times the kidney becomes tender and swollen as a result of twisting of 
the renal vessels or of the ureter (Dietl's crises), causing engorgement of 
the organ; this may be associated with agonizing pain and symptoms of 
collapse. Hydronephrosis msiy be manifested. 

Diagnosis. — The shape of the tumor, marked mobility, and lessen- 
ed resistance on percussion of the renal region will make the diagnosis. 
The disorder very rarely proves fatal. In doubtful cases utiHze the 
X-ray. 

Treatment. — Many cases rarely give trouble directly, but may be 
a source of reflex and obscure symptoms. Attention to the general 
health of the patient and persistent treatment of the dorso-lumbar region 
greatly strengthen the relaxed tissues about the kidney and cure a num- 
ber of cases. Having the patient attempt to replace the organ after he 
goes to bed will be of value. Treatment of the abdomen to strengthen 
the walls and lessen any hver congestion and to keep the bowels active 
is very beneficial. Teach the patient how to stand and walk correctly, 
especially holding the abdomen in and up. A liberal diet to the point 
of increasing the weight is worthy of trial. The use of supports is not 
always satisfactory. Surgical treatment for fixing the kidney is of per- 
manent value, but do not advise operation unless absolutely indicated. 
(See Prolapsed Organs, Part I). 

To determine the presence of a movable kidney, it is best to 
have the patient in the dorsal position, the head shghtly lowered and the 
abdominal walls relaxed by flexing the thighs moderately upon the ab- 
domen. Then with the left hand in the lumbar region behind the elev- 
enth and twelfth ribs, and the right hand in the hypochondriac region, 
the kidney can usually be detected after full inspiration followed by com- 
plete expiration; or, have the patient in a standing posture with the bodj^ 
bent shghtly forward and the hands placed upon a table, then perform 
bimanual palpation; or, perform the manipulation in the knee-elbow 
l^osition. When in this position (knee-elbow),, if the kidney has become 
dislodged, a resonant note will be obtained by percussion over the nor- 
mal location of the kidney. 

DISEASES OF THE BLADDER 

Cystitis 

Cystitis is an inflammation of the mucous membrane of the blad- 
dci-. Retention of the urine; foreign bodies, such as stones, in the blad- 
der; the use of dirty catheters; exposure to wet and ookl; injuries to the 



636 The Practice of Osteopathy 

bladder and over the pubes; irritations to the sacral nerves; spinal lesions 
in the dorsal enlargement of the cord; innominate lesions; irritating drugs; 
enlarged prostate and urethral strictures are the principal causes of cys- 
titis. The disease may be secondary to fevers, infectious diseases and 
inflaimnation of adjacent organs. A displaced uterus may produce a 
chronic irritation of the bladder. . 

Pathologically, there is hyperemia of the mucous membrane of 
part or of the whole of the bladder, with redness, congestion and edema. 
The secretion of mucus that covers the mucous membrane is of a dirty 
gray color. If the congestion is very extensive, a bursting of the capil- 
laries may take place. In a few cases the neck of the bladder and the 
urethra, where it passes through the prostate, is involved. In chronic 
cases the mucous membrane becomes thickened and covered with patches 
of false membrane. The muscular coat of the bladder becomes hyper- 
trophied and the veins tortuous. 

Symptoms. — The onset may be sudden with rigors and fever, but 
in many cases a frequent desire to micturate wiU be the first symptom. 
This is followed by tenderness and pain over the bladder and contigu- 
ous parts, loss of appetite, depression and sleeplessness. Tenesmus of 
the bladder, caused by a spastic condition of its muscles, and a burning 
along the urethra are usually present. The urine is alkaline in reaction 
and contains pus, epithehum and blood. 

Diagnosis.— The diagnosis is usually easy. Pyelitis causes pains 
in the lumbar region and along the ureters and there is a frequent desire 
to urinate. The bladder is not subject to spasms and the urine is of an 
acid or neutral I'eaction. 

Prognosis. — In many cases the prognosis is favorable, but in cases 
of long standing and in hypertrophy' of the bladder, prognosis must be 
guarded. 

Treatment. — Rest in bed with strict attention to diet is necessar3\ 
Milk is the best food and avoid highly seasoned articles and acid foods. 
The use of plenty of pure water is helpful to dilute the urine, and if neces- 
sary the bladder should be washed out carefully. If the case is severe, 
emptying the bladder several times a day with a catheter wiU be neces- 
sary. Always be careful about the cleansing of the instruments. Warm 
applications over the pelvic region will be comforting to the patient. 
Lifting the abdominal viscera from the bladder is of assistance. The 
patient maj^ be placed in the knee and chest position for this or the usual 
method employed. 



The Pkactice of Osteopathy 637 

Treatment to the second, third and fourth sacral nerves controls 
the neck of the bladder, and strong inhibition will generally control the 
spasms of the sphincter. The fundus of the organ is supplied by sympa- 
thetic fibers from the pelvic plexus. Direct treatment over the bladder, 
if applied carefully, will act on the terminal fibers of the sympathetic. 
Lesions to the nerves of the sphincter of the bladder oftentimes occur 
between the fifth lumbar and sacrum, also from a displaced innominate. 
Such lesions are apt to be found in cases of incontinence of urine. The 
lesion to the vertebra is usually a lateral one. 

Thorough treatment to the genito-urinary center (lower dorsal and 
upper lumbar) will also be of aid. In males direct treatment of the pros- 
tate gland is occasionally important as is also the plexus of nerves at 
the trigone of the bladder. In treating the prostate gland introduce 
a finger into the rectum and work about the base of the gland to relax 
the tissues, and thus remove obstructions of the vascular, lymphatic and 
nervous structures to the gland. Do not work too much upon the gland 
itself (commonly once a week or ten days), as it may irritate, but release 
surrounding edema. Also treat the innervation at the eleventh and 
twelfth dorsals, fifth lumbar, and first, second and third sacrals. Spread- 
ing the ischii will occasionally be beneficial; this tends to release the an- 
terior commissure where it is attached to the symphysis. 

Follow the above with a "general treatment" in order to secure 
a general systemic reaction. This is of value in all infectious disorders. 

It is important in young boys to examine the condition of the 
penis in bladder diseases. The prepuce may become adherent or other 
irritations may be found that are a source of disturbance to the bladder, 
or even to the kidneys, on account of the intimate connection of the 
sympathetic system in this region and the relation of one organ to an- 
other. 

An irritable bladder is usually due to disorders of near-by tissues, 
especially the urethra, vagina, uterus and rectum. 

Enuresis, exclusive of paralysis, is frequently due to some local 
mechanical disturbance. Nocturnal enuresis or bed wetting is caused 
by lower dorsal and lumbar lesions (especially the fifth lumbar), dis- 
placements of the innominate, or phimosis, hooded clitoris, contracted 
meatus, highly acid urine, worms, lack of discipHne, etc. The patient is 
usually neurotic, which demands attention to the neuromuscular sys- 
tem of the entire body. Care of the general health and habits is impor- 
tant. Constipation may be present. 



638 The Practice of Osteopathy 

DISEASES OF THE CIRCULATORY SYSTEM 

DISEASES OF THE PERICARDIUM 

Pericarditis 

Pericarditis is an inflammation of the serous membrane covering 
the heart and its reflection in front over the chest. Primary inflamma- 
tion of the pericardium is rare. Such cases usually result from cold 
and exposure or injury or tuberculosis, and are most commonly met with 
in children. 

The exciting causes of secondary pericarditis are rheumatism, 
Bright's disease, tuberculosis, gout, diabetes, eruptive fevers, various 
septic conditions and dyscrasia. Pericarditis may result by extension 
of inflammation from contiguous organs, as the disease may occur in 
pneumonia, pleuropneumonia, chronic valvular diseases, and ulcer- 
ative diseases of the esophagus, bronchi, vertebrae, ribs, stomach, etc. 

Displacement of the ribs over the heart and involvement of the cor- 
responding vertebrae predispose to pericarditis, by weakening the inner- 
vation of the pericardium and thus disturbing the circulation. Lesions 
of the cervical region affecting the left phrenic are to be considered. 
Upper rib lesions may disturb the internal mammary artery and the 
Ijmiphatics, which have important relationship with the pericardium. 
The disease may occur at any age. Males are more frequently attacked 
than females. 

The morbid conditions vary with the stage. The stages are (1) 
acute, plastic, or dry pericarditis; (2) pericarditis with effusion, sero- 
fibrinous, hemorrhagic or purulent; (3) absorption or adhesive pericarditis. 
These different stages or varieties commonly succeed one another, al- 
though medical writers place so much importance in them that each is 
described separately. Acute pericarditis is by far the most common 
and often the inflammation subsides at this point instead of going on 
to more serious involvement. There is a possibility that in some cases 
the forms are independent of each other. 

The changes are the same as in various serous membranes. Hyper- 
emia and alteration of the epithelium is most marked on the visceral 
layer. This is followed by an exudation from the hyperemic vessels. 
There is roughening and loosening of the epithehum and the fibrin is pre- 
cipitated upon the walls of the pericardium. More or less lymph is 
exuded and sometimes injected capillaries burst and cause a bloody ex- 
udation. From this stage the morbid appearances vary according to 
the progress of the disease. The disease may undergo resolution and 



The Practice of Osteopathy 639 

fatty degeneration and absorption of the products in point take, place. 
As the stage of effusion occurs, the parietal and visceral layers of the 
pericardium are separated by ^ serofibrinous exudate. This condi- 
tion may increase until the quantity of the exudation is considerable, or 
the effusion may become absorbed. Rarely does the exudate become 
purulent. 

Adhesions may be formed between the layers of the pericardium, 
during the last stage, by bands of various lengths or the layers are more 
or less separable. 

Symptoms. — Simple cases may not present any symptoms. Usual- 
ly a chill or cold feeling at the heart, followed by pains in the cardiac 
region, ushers in the attack. Fever is com.monly present, rarely exceed- 
ing 103 degrees F. Tenderness over the heart is noticeable. There is 
dyspnea and the patient is restless. 

In the effusive stage the symptoms depend largely upon the amount 
of diffusion. The pain is sharp and stitch-like. Nausea, vomiting and 
hiccough sometimes occur. The pulse is irregular and feeble. Insom- 
nia, headache and even delirium may occur. Distention of the veins 
of the neck may cause dysphagia and a cough maj^ be present, owing to 
the irritation of the trachea. The recurrent laryngeal nerve may be 
compressed as it winds about the aorta and thus cause aphonia. 

The friction sound is a characteristic physical sign of the first stage. 
In the effusive stage there may be precordial bulging. The area of dull- 
ness is enlarged, the diaphragm and liver may be crowded downward, 
causing an epigastric bulging. As the effusion increases, the heart sounds 
become less distinct; the friction is not heard. In the fhird stage there 
is usually a return to normal, although adhesions may form and cause 
precordial retraction and permanently embarrass the heart's movements. 
The young are more subject to permanent disabiKt3^ Extension of 
heart impulse, which is undulatory; diastoHc shock to hand placed over 
heart; increased area of dullness; prominent precordia; position of pa- 
tient does not change apex beat; and when pericardium is adherent to 
diaphragm a systolic tug is noted over points of attachment, are essen- 
tial signs and symptoms. 

Diagnosis.' — Pericarditis is frequently overlooked. It is a serious 
disease and one should be especially careful. In cases of rheumatism 
the osteopath must always be on his guard. Tonsillitis may be the ori- 
gin of the infection. Care has to be taken in distinguishing between 
dilatation and cardiac hypertrophy and pericardial effusion. Hydro- 
pericardium may be mistaken for pericardial effusion. 



640 The Practice of Osteopathy 

To distinguish between endocarditis and pericarditis should not be 
a difficult task if one understands thoroughly the nature of each dis- 
ease. A large pericardial effusion may be confounded with a pleural 
effusion. In doubtful cases utiHze the X-ray. 

Prognosis. — In mild cases of pericarditis the large majority rapidly 
recover in two to three weeks. In cachectic subjects and where ad- 
hesions have formed, the duration is longer. Relapses may occur. The 
purulent effusions are alwaj'S serious. 

Treatment. — Demands prompt and effective measures. Absolute 
rest mentally and physically, is necessary. Too much stress cannot be 
laid upon this point, as death has occurred from neglect of this. To 
quiet the heart's action is the first necessary requisite, and then give 
treatment to hmit the inflammation. In the early stage relaxing the 
upper dorsal musculature to control innervation, and raising and freeing 
all the upper ribs and clavicles to promote lymphatic drainage is effective. 
In the second stage prevention of cardiac failure and promotion of ab- 
sorption are the indications to be met. Too much importance cannot 
be placed upon the point that general strength, good nursing, dieting and 
free elimination are essential, not only in securing a rapid subsidence of 
the inflammation, but to prevent further complications. 

Raising and separating the ribs over the heart will be of great aid 
in lessening the inflammation and promoting absorption. In many cases 
lesions to the ribs on the left side and subdislocations of the vertebrae 
affecting the vasomotor nerves, the lymphatics and nerves to the heart 
will be found. The first five ribs and corresponding vertebrae is the re- 
gion where one may expect to find the lesions. In addition to absolute 
rest, an inhibiting treatment in the dorsal region between the scapulae 
will aid in slowing the heart's action. Correcting any lesion that may be 
found to the vagi nerves will also be a help in controlhng the heart's 
action; besides, most of the vasomotor fibers to the heart are in the vagi. 
These lesions are usually found at the atlas. One should also examine 
carefully all the cervical vertebrae for derangements that might affect 
the cervical sympathetic, especially the superior and middle cervical 
gangha. These gangha are primaril}^ affected from the fifth cervical to 
the first dorsal. Inhibition for a few minutes between the transverse 
process of the atlas and the occipital bone to the posterior occipital nerves 
will be of great aid in controlhng the tumultuous action of the heart; 
also, inhibit in the upper dorsal. The warm bath wiU quiet the heart, 
but care should be taken not to weaken the patient. The general treat- 
ment has the effect of lessening nervousness and quieting the heart. 



The Practice of Osteopathy 641 

The function of the phrenic nerve must be borne in mind when re- 
garding the pericardium. The phrenic is usually primarily affected at 
the third, fourth and fifth cervicals, and occasionally there are connect- 
ing fibers as low as the fourth and fifth dorsals. Ice-bags may be found 
of value in retarding the progress of the effusion and in lessening the 
heart's action. Liquid food, as milk and broths, should be given through- 
out the disease. If the effusion is very large the services of a surgeon 
should be secured and tapping performed. If the effusion is of a purulent 
nature, a free incision should be made with antiseptic precautions. 

In chronic cases carefully graduated breathing exercises and mod- 
erate stretching of the adherent regions, if pathology permits, should 
be considered. 

Endocarditis 

Endocarditis is an inflammation of the lining membrane of the 
heart. The process is usually confined to the valves; the fining of the 
cavity of the heart may also be affected, especially in severe cases. Three 
forms are recognized : simple acute endocarditis, ulcerative endocarditis, 
and chronic endocarditis. 

Simple Acute Endocarditis. — This form usually results from 
acute articular rheumatism. Tonsillitis may be associated with endo- 
carditis. It may also be caused by other infectious diseases, especially 
scarlet fever, but rarely, b}^ typhoid fever, measles, chicken-pox, diph- 
theria, small-pox and erysipelas. Acute endocarditis is frequently found 
in chorea. It is also met with in diseases attended with emaciation and 
general weakness, as cancer, gout, Bright's disease and diabetes. It is 
not uncommon in phthisis. Micro-organisms play an exciting part, 
but back of this the osteopath finds lesions of the heart innervation im- 
portant predisposing features. Prophylactic osteopathic treatment is a 
potent factor in preventing endocardial changes in the above diseases. 
Keeping the muscles relaxed and the osseous tissues intact is of great 
value. 

Pathologically, the left side of the heart is most commonly in- 
volved. The disease is characterized by the presence of small vegeta- 
tions on the segments or on the lining membrane of the chambers, al- 
though in mild cases there is simply sweUing of the valves. The mitral 
valves are more often affected than the aortic. The vegetations appear, 
usually, on the auricular surface of the mitral and the ventricular sur- 
face of the aortic valves, a little back of the valve edge. Their seat cor- 
responds to the point of maximum contact (Sibson). These growths 



642 The Practice of Osteopathy 

are liable to be broken off at any time and carried as emboli by the blood 
current to distant organs, particularly the brain, spleen and kidneys. 
This is not uncommon in acute endocarditis or chronic valvulitis. In 
favorable cases the vegetation is ultimately absorbed and the valve is 
but sUghtly altered beyond a simple sclerotic thickening. This is often 
the starting point of sclerotic valvulitis. Osteopathic measures un- 
doubtedly lessen the liability of cardiac involvement, prevent extensive 
changes and promote absorption of disease products, by lowering heart 
tension and improving the cardiac nutrition, as well as increasing free 
ehmination of the toxins in the blood. 

During the fetal life, the right side of the heart is most commonly 
involved. The chorda tending are sometimes affected, but rarely alone. 

The vegetations are composed of proliferated connective tissue cells. 
The superficial elements undergo a coagulation-necrosis and fibrin is 
deposited from the blood. Micro-organisms are found and are the 
specific agent in causing acute endocarditis. 

Symptoms. — A large number of cases are latent, the autopsy first 
disclosing the lesion. In many cases there are shght fever, a frequent, 
sometimes irregular, pulse, palpitation and dyspnea. There is seldom 
any pain. 

Physical signs are very uncertain. They may not be present in 
mild cases and in those in which the valves are not affected. Usually 
auscultation furnishes the only indication of endocarditis — a soft, blow- 
ing, systolic murmur which is heard most frequently at the apex, as the 
mitral valves are the ones generally involved. When the aortic valves 
are affected, the murmur is heard at the second interspace at the right 
edge of the sternum. 

Diagnosis. — This depends entirely upon the etiology and physical 
signs. The greatest danger is in the disease becoming chronic. 

Treatment. — The patient should be kept as quiet as possible, so 
that the work required of the heart may be reduced to a minimum. The 
disturbed circulation can be controlled by careful attention to the vaso- 
motor nerves at the various centers along the spine. Attention should 
be given the disease that is causing the endocarditis. Keep the patient 
w^ell protected by flannels and beware of damp rooms and sudden changes 
of temperature. 

Treatment should be given to correct anj^ lesion found in the upper 
five dorsal vertebra? or ribs and to raise and spread all of these ribs so 
that the heart's action will not be unduly disturbed by interferences with 
its innervation. The vasomotor nerves to the heart's vessels are found 



The Practice of Osteopathy 643 

in the vagi nerves, consequently care should be taken that lesions to 
these nerves do not exist. An inhibitory treatment to the sub-occipital 
nerves acts refiexly on the vasomotor nerves and tends to equahze the 
general vascular system. This treatment qviiets the heart's action. Ice 
appHed locally is advocated by many practitioners. Flannels should be 
placed next to the skin and the ice-bag placed over the flannel. This 
reduces the fever, lessens the pulse-rate and quiets the heart action. 
The same points are obtained by the inhibitory treatment at the sub- 
occipital region. The ice-bag also relieves pain and oppression. Be 
very careful in the use of ice when there is much cardiac dilatation. Treat- 
ment of the middle and inferior cervical regions may have some effect in 
controlHng the heart's action. A general treatment to quiet the patient 
is effective. Do not allow any overexertion. The patient should have 
nourishing Hquid food. 

Emery^ says: "Many of us have been in the habit of saying, just 
because we hear a decided murmur in the heart region, that the patient 
has valvular heart trouble; that the patient has organic heart trouble. 
This is a common error . . . When there is an anemic condition of 
the body, apparently the cusps of the valve will be so weakened, and 
the attachment will be so weakened that the blood will force its way 
between the valves and back into the heart, causing regurgitation mur- 
mur, when as an actual fact there is no deformity and no real disease of 
the valves, and as soon as the general condition of the anemia is im- 
proved, the valve will do its work fully and the murmur entirely cease. 
So if you have the murmur without the hypertrophied condition, which 
at once follows such a valvular lesion, you must be guarded in your 
statements, for if an actual valvular lesion existed, compensation would 
take place, and it would be the means of corroborating such a valvular 
condition; if no hypertrophy is found, then we are not justified in defi- 
nitely stating that a valvular or organic lesion exists, for such a weakened 
condition as has been mentioned might be the only pathology present, and 
be the cause of the murmur. " 

Ulcerative or malignant endocarditis. — This is an acute, in- 
fectious or septic disease, characterized locally by necrosis or ulceration 
of the valve. It is generally a secondary affection to septicemia, pneu- 
monia, erysipelas, scarlet fever and acute rheumatism. Acute endo- 
carditis often precedes the ulcerative variety, the latter being simply an 
increase in severity of the former. 

Etiology and Pathology. — It is doubtful if there can be a primary 

1. Journal of the American Osteopathic Association, April, 1906. 



644 The Practice of Osteopathy 

form of ulcerative endocarditis. Chronic valvular defects are the most 
important predisposing causes. Pneumonia is most frequently, of all 
the acute diseases, associated with severe endocarditis. It is rare in 
tuberculosis, diphtheria, typhoid fever and chorea. It occurs in asso- 
ciation with erysipelas, gonorrhea and rheumatism. Septicemia, pleur- 
isy, meningitis and puerperal fever are other possible causes of ulcer- 
ative endocarditis. 

Deep seated lesions, which means firmh' anchored lateral flexions 
and rotations due to fibrotic changes, are important predisposing local 
factors, while other lesions that disturb blood elaboration and resist- 
ance and lessen elimination, are predisposing systemic causes. 

Pathologically, the lesions are cither vegetative, ulcerative or 
suppurative. The vegetations are composed of granulation tissue, 
granular and fibrillated fibrin, and colonies of micro-organisms. They 
become necrotic and break down into ulcers. The ulcerative changes 
ma}^ lead to perforations or produce valvular aneurisms. Of the valves 
the mitral is the most frequentty ajffected; then the aortic; then the 
mitral and the aortic together; then the heart walls; then the tricuspid; 
then the pulmonary. In a few cases the right heart alone is involved. 
The lesion is not always confined to the valves, but may involve the 
mural endocardium. The most common organisms found are the pneu- 
mococcus, streptococci and staphylococci. The bacillus diphtherise, ba- 
cillus coli, gonococcus, bacillus anthracis and other organisms have been 
found. Associated pathological changes include the lesions of the pri- 
mary disease and the changes due to embolism. The spleen, kidneys, 
brain, intestines and skin may be the seat of embohsm. When found 
in the lungs, they originate in the right heart. 

Symptoms. — If in the course of any of the diseases previously 
named under etiology, chills followed by fever and sweats occur, ulcer- 
ative endocarditis should at once be suspected and a thorough examina- 
tion be made. The general sjTiiptoms are high, irregular fever, dehr- 
ium, sweating, great prostration, rapid pulse, hurried breathing and 
sometimes jaundice and diarrhea occur. 

The occurrence of dehrium, coma or hemiplegia points to involve- 
ment of the brain; pain in the region of the spleen, with increased dull- 
ness on percussion, point to trouble in that organ; hematuria may occur 
from involvement of the kidne3's. More rarely there will be impaired 
vision from retinal hemorrhage; and there may be suppuration and 
sometimes gangrene in various locations, depending upon the position 
of the embolism. 



The Practice of Osteopathy 645 

The septic type is secondary to suppurating external wounds, 
puerperal sepsis or acute necrosis. Occasionally gonorrhea is the cause. 
The sjanptoms presented are rigors, irregular fever, sweats and exha\is- 
tion— the signs of septic infection. The sjrmptoms may resemble a 
quotidian or a tertian ague. The typhoid type is the most common. 
The characteristic symptoms are irregular temperature, sweating, pros- 
tration, delirium, drowsiness, diarrhea, petechial and other rashes, dis- 
tention of the abdomen and pain in the right iliac region. The heart 
symptoms may be overlooked, as in the septic type. The cardiac 
type are cases of chronic valvular diseases in which fever, rigors and 
sweats, and the symptoms of embohsm may develop. In the cerebral 
cases the sjanptoms may simulate meningitis. Acute delirium may be 
the distinctive symptom. Heart symptoms may be overlooked. 

Physical Signs. — The heart symptoms may be latent. Even after 
a careful examination, there may be no murmur present. When mur- 
murs are present it is often difficult to locate them. 

Diagnosis. — The previous history should be considered and this, 
together with the symptoms, makes a correct diagnosis possible, even 
though physical signs are absent. The duration is from a few days to 
several weeks. 

Treatment. — The treatment of this form of endocarditis is likely 
to be of little avail, although in a few cases where the source of infec- 
tion can be eradicated the condition may be considerably improved and 
life prolonged. About the same treatment as in simple endocarditis 
should be followed. Absolute rest is essential and this, coupled with the 
local treatment of simple endocarditis and a nourishing liquid diet, con- 
stitutes the principal treatment. 

Chronic Endocarditis 

This condition may begin as a chronic inflammation or follow the 
acute form, which is more often the case. There is a sclerosis of the 
valves which causes deformity, owing to the contractions. The onset is 
usually insidious. 

It is well known that the larger percentage of valvular lesions are 
the result of either acute or chronic endocarditis. Thus rheumatism 
stands foremost as a cuase of valvular defects. Alcoholism and over- 
eating (through introducing irritating influences into the blood, or by 
causing rheumatism, gout and allied diseases) are important etiological 
considerations. Nephritis and syphilis arc considered among the causa- 
tive factors. Infections and senility, when associated with high blood 



646 The Practice of Osteopathy 

pressure, is a phase not to be overlooked. Chronic endarteritis extend- 
ing from the aorta to the valves, resulting in thickening and degenera- 
tion of the tissue, may be an insidious source of valve disease. This is 
probably often of syphilitic origin. 

A potent cause of special interest to the osteopath (for the reason 
that his treatment is so effective), is continued muscular strain as 
seen in athletes and laborers. The heart muscle itself may be strained, 
particularly the valve leaflets and the tissues about the valve, which 
effect often terminates in valvular leakage. In addition, the orifice of 
the valve openings may become stretched and distorted through strain 
superinduced by prolonged exertion, by flabbiness of heart tissue, and 
by dilatation of the ventricles. In these latter cases it is seen that the 
leaflets of the valves may remain intact, but still they are unable to 
stretch completely across the opening. 

With the above condition it is readily noted that thickening, curling 
and adhesions will take place when inflammation attacks the valves and 
contiguous tissues, and following these, limy infiltration and fatty de- 
generation may be a consequence. 

Predisposing osteopathic lesions as noted in acute endocarditis, are 
not to be neglected. 

Thickening and liyperplasia are immediate consequents of con- 
nective tissue overgrowth; and especiall}^ is chronic endarteritis accom- 
panied with atheromatous and calcareous degeneration. Thickening, 
at times, is only slight and the function of valves is not impaired. 

In curling or retraction, there occurs a shrinkage of the hyper- 
trophic or hyperplastic tissues. This condition is very apt to become 
permanent. 

Adhesions of the valve leaflets is a self-evident condition. It is 
well to note here that in acute and chronic endocarditis some part of 
the fibrous valve ruptures or is lacerated or eroded from strong and rapid 
heart action; the laceration or rupture or erosion always occurs at the 
point of maximum contact. Thus the eroded surface allows an oppor- 
tunity for the rhemnatic or septic micro-organisms to lodge, multiply and 
grow, and adhesions result. Carefully applied osteopathic methods are 
very efficacious in impending acute heart disturbances, and this without 
doubt is the reason why so many of our rheumatic cases get well without 
any heart affections. Keeping the heart quieted and slowed prevents 
the strong and rapid action and thus lessens the probability of lacera- 
tions, ruptures and erosions of the valve tissues. General resistance- i? 



The Practice of Osteopathy 647 

increased and eKmination improved, which have a decided effect in pre- 
venting comphcations. 

Calcification and atheroma, as has been mentioned, may follow 
the above diseased processes. The calcification is sometimes so marked 
as to be of the character of a bony ring. 

The question arises here, What effect have osteopathic lesions as 
direct causative factors in valvuHtis? It appears reasonable that the 
heart is not exempt from the influences of the vertebral and rib mal- 
adjustments. Furthermore, clinical experience has abundantly proven 
that the heart tissues are affected by these lesions in the same manner as 
any tissue or organ is affected. Again, osteopathic dissection reveals 
direct nervous connection from the upper dorsal spinal ganglia to the 
heart ganglia. 

No one will question that the integrity of heart function and life 
are dependent upon normal coronary artery supply, upon vasomotor 
equihbrium, and upon motor control. All of these functions are influ- 
enced by the status of cervical vertebrae, upper dorsal vertebrae, and rib 
relations. Just what the pathological affection is when these anatom- 
ical parts are disturbed is beyond us until more careful dissection and ex- 
perimentation have taken place. How cervical and dorsal sympathet- 
ics, vasomotor and motor nerves with their spinal connections, vagi and 
phrenic, are so disturbed as to involve valvular parts and induce inflam- 
mation, is a problem for us to investigate. Through analagous reason- 
ing from other organic ailments and through the fact that osteopathic 
therapeutics corrects heart lesions, we know in a general way that the 
correction of osteopathic lesions decidedly influences the heart. 

Two well known physiological facts relative to the heart are: 
first, the heart increases in size up to adult life, and, second, the heart 
muscle can actually be increased in size. This latter fact occurs in phys- 
ical development and training. A heart that is weak and flabby can be 
increased in strength, tone and size. This helps us to understand how 
certain strains and distortions of the heart, with consequent valvular 
lesions, may be corrected through rest, exercise and treatment; some- 
what analagous to the correction of an atonic, prolapsed and dilated 
stomach. Then it also seems probal)le that disturbed innervation and 
blood supply to heart areas or to the heart as a whole would predispose 
to congestions, inflammations and degenerations whereby rheumatism, 
septic states, etc., and muscular strains would act only as exciting causes, 
not true causes. 

No one is going to expect that thickened, retracted, adhered, or 



648 The Practice of Osteopathy 

ruptured valves are to be made anatomically correct ; but the right treat- 
ment will certainly reduce the morbid state to the minimum. Then 
there are cases where osteopaths have ehminated all murmurs when 
specialists stated the disease was incurable; showing that it is impossible 
by signs and symptoms to always diagnose the morbid tissue state. Only 
the resulting effects of size and of leakage are definitely revealed by aus- 
cultation and percussion. Hence there is a class of valvular diseases 
that can be successfully treated by osteopathic measures, which, if left 
to terminate under drug medication, will reveal (at post-mortem) the 
pathological signs of valvular heart disease. 

Downward displacement of the first rib may interfere directly with 
the subclavian artery and thus cause constriction of that vessel and a 
consequent regurgitation; also, cardiac fibers of the recurrent laryngeal 
nerves may be impinged by a dislocation of this rib. Many lesions which 
interfere with the right side of the heart occur at the second and third 
ribs and lesions of the third, fourth and fifth ribs maj^ interfere with 
the valves. Lesions of the corresponding vertebrae produce the same 
results as the ribs. These lesions are probably to the sympathetic nerves 
along the dorsal region. Lesions may be found anywhere along the cer- 
vical vertebrae which may involve inhibitory (vagi) fibers or accellerator 
(sympathetic) fibers to the heart. Also, in some cases the floating ribs 
are dislocated downward and cause a prolapse of the diaphragm, and thus 
a constriction of the aorta, which may result in regurgitation and valvu- 
lar disorder. 

Mitral Regurgitation. — Mitral regurgitation is a leakage of blood 
from the left ventricle, through the mitral valves, into the left auricle. 
The opening of the valve may be distorted, or the valve leaflets thick- 
ened, rigid, or retracted, thus allowing an escape or reflux of blood from 
ventricle into auricle. The tendinous cords may also be thickened and 
adhered, with consequent prevention of free action. 

By a forcing back of a portion of the blood from ventricle to auricle 
at the same time the pulmonic veins are emptying into the auricle, an 
overdistention of the auricle takes place. The auricle, then, from the 
extra amount of work required, becomes hypertrophied and dilated. 
There may be no noticeable symptoms at first. Later on shortness of 
breath, cough, irregularity of heart's action, indigestion, liver conges- 
tion, and so on, occur. 

The apex beat is forcible and downward to the left. Of course the 
area of dullness is to the right and left. There is a systolic murmur 
in the mitral area, which is transmitted to the left nxilla. 



The Practice of Osteopathy 649 

Every osteopath should understand the mechanism of this most 
frequent valvular lesion. Following hypertrophy and dilatation of the 
left auricle, the reflux may be so excessive that a residue remains. The 
auricle not being able to handle all the blood, stasis of the pulmonary 
vessels takes place, and pulmonary edema and hydrothorax are sequelae. 
Then comes dilatation of the right ventricle and back pressure on tri- 
cuspid valves and right auricle. The veins throughout the body become 
turgescent, and the liver is apt to be indurated. It should be emphasized, 
however, that "back pressure" is only an effect commonly due to myo- 
cardial degeneration, caused by some infection, of which auricular fibrilla- 
tion is an important part of the pathology. 

Before the breaking down of the left heart compensation, osteopathic 
methods, as all know, are effective in maintaining balance. Even after 
the lungs begin to be affected, careful and thorough treatment will result 
in good, and in cases of general venous sluggishness treatment, particu- 
larly to liver, diaphragm, bowels and limbs, will generally materially 
help in slowing the downward course of the disease. 

Mitral Stenosis. — In stenosis there is narrowing or constriction of 
the valve opening. Thus in mitral stenosis the free flow of the blood from 
left auricle to ventricle is hindered. 

The cusps are usually thickened, rigid and adhered. The valve 
opening may be so stenosed as to be but a narrow slit. In all cases ste- 
nosis is a structural defect. It can occur by strains, as regurgitative 
effects sometimes result. 

The symptoms of mitral stenosis are practically the same as those 
of mitral regurgitation, owing to similar effects upon the circulation. 

Under physical signs we find the apex-beat is only slightly dis- 
placed. Palpation will reveal, near the apex, a rough presystolic thrill. 
The increased area of dullness is to the right. There is an abruptly ter- 
minating, rough, presystoHc murmur. 

Aortic Regurgitation. — Aortic regurgitation is a reflux of blood 
from aorta to left ventricle, following ventricular systole. This is con- 
sidered the most serious of the valvular diseases. The valve opening 
is either too large, so the valve leaflets do not fit tightly, or the segments 
themselves arc thickened and retracted. Structural defects of the aortic 
valves are lai-gcly of the same character as in diseases of the mitral valves. 

The regurgitation first causes dilatation of the left ventricle. This 
is followed by hypertrophy. If the mitral valve holds intact, no further 
effects result. But if the mitral valve is diseased or becomes incompe- 



650 The Practice of Osteopathy 

tent from the dilated ventricle, the same morbid states follow as was 
noted under mitral regurgitation. 

There is a forcible apex-beat, displaced downward to the left. The 
increased dullness is to the left. There is a long, loud diastolic mur- 
mur. The well known "water-hammer" pulse is felt. 

Aortic Stenosis. — Aortic stenosis indicates a narrowing of the 
aortic orifice. It is a structural defect. The free flow of blood is ob- 
structed from the left ventricle into the aorta. 

Aortic stenosis is much less frequent than regurgitation. Aortic 
stenosis and regurgitation are very apt to be associated. The beat is 
commonly forcible, and the increased area of dullness is to the left. There 
is a systolic murmur, heard best at the right second interspace, which is 
conducted into both carotid arteries. 

Tricuspid Regurgitation. — Tricuspid regurgitation is the most 
common valvular lesion affecting the right heart. It is rare as a primary 
lesion. The affection may be of a structural character, or functional. 

Hypertrophy of the right ventricle occurs after the manner of left 
ventricle hypertrophy in mitral regurgitation. The sequelae of venous 
turgescence follow, also, in the same way as was given under the mitral 
lesions. Tricuspid regurgitation rarely exists independent of some other 
cardiac or pulmonar}^ ailments. 

The apex-beat is diffused toward the epigastrium. Increased cardiac 
dullness is toward the right. There is a systolic murmur, which is heard 
best just above the xiphoid cartilage. The jugular vein pulsates; in 
severe cases there is pulsation of the liver. 

Osteopathic treatment is usually effective in reheving the engorge- 
ment of the veins, and particularly in reducing liver congestion. 

Tricuspid Stenosis. — This affection is said to be the most rare 
of valvular lesions. Thickening, obstruction and adhesions from endo- 
carditis cause the stenosis. As in other lesions of the heart, there is a 
congenital form. There is pre-systolic murmur, heard best at the xi- 
phoid cartilage. The pulse is small and weak. 

Pulmonary Regurgitation. — This is another rare lesion, and is 
seldom met with in a simple form. 

There is forcible pulsation in the epigastrium. Increased cardiac 
dullness is downward. There is a diastohc murmur, heard most dis- 
tinctly at the left second intercostal space. 

Pulmonary Stenosis. — Another rare lesion. The effect of this 
lesion on the right ventricle is the same as that of aortic stenosis on the 



The Practice of Osteopathy 651 

ieft. The congenital lesion is apt to occur with a patulous foramen 
ovale. 

There is a systohc murmur, heard best at the second intercostal 
space on the left. Many systolic murmurs heard over the pulmonary 
opening are functional. 

Combined Valvular Lesions. — When two or more lesions occur 
at the same time the ternis, combined or associated, are employed. This 
is a very common occurrence. Two, three or all of the valves may be 
affected at the same time. Stenosis and regurgitation at the sajne 
orifice is the most common association of any two valvular lesions. When 
there is a joint affection of two or more valves, the aortic and mitral 
are most commonly associated; then mitral and tricuspid; then aortic, 
mitral and tricuspid . 

Prognosis and Treatment of Valvular Diseases. — It is impos- 
sible to outline with exactness either prognosis or treatment of heart 
lesions. All will agree that the character of the lesion is the first con- 
sideration, and before records of these cases can be of any scientific bene- 
fit, we must look well to the nature of the valvular leakage or obstruc- 
tion and note precisely what effect our therapeutics has. Perhaps of 
greatest consideration in the matter of prognosis is, to what extent com- 
pensation has been maintained. We know that compensation may be 
perfect; that hypertrophy and dilatation may balance the valvular de- 
fect so thoroughly that even the patient is not aware of a heart lesion. 
As soon as compensation begins to fail, when palpitation, irregularity of 
pulse, dyspnea, edema, etc., appear, we know that our treatment should 
pass from the realm of the defensive to that of the offensive. Then when 
compensation fails still more, prognosis and treatment must necessarily 
be changed according to the increasing gravity. 

In our osteopathic work we should never forget that the condition 
of the lesion may be greatly influenced by environment. Habits, occu- 
pation and general daily fife may affect the heart ailment for good or bad. 
Thus in prognosis we have three features in particular to note : char- 
acter of heart lesion, extent of systemic involvement, and environment. 
In the immediate prognosis, the extent of general venous stasis, if any, 
is of great importance. In other words, the gravity of the complications 
is of first consideration. 

Aortic regurgitation is ranked by heart specialists as the most ser- 
ious lesion. Aortic stenosis is a grave lesion, but not so serious as aortic 
regurgitation. It is often stated that the character of the lesion is not 
of so much consequence as the extent of involvement the lesion has en- 



652 The Practice of Osteopathy 

gendered. Mitral stenosis is more grave than mitral regurgitation. 
Right side heart lesions are usually relative, and, naturallj^, when the 
right heart is diseased from extension of the ailment from the left side, 
the situation is serious. 

It should be remembered that a heart normal in size and beating 
regularly is usually in a fairly healthy condition even if a murmur is 
present. 

In our treatment the first point indicated is to improve, if pos- 
sible, the integrity of lieart muscle and lessen the valvular defects, 
if such can be done. Owing to a dearth of statistics, it is impossible to 
state to what extent improvement in organic lesions has been accom- 
plished. Very Kkely if we had statistics and no post-mortem findings, 
we would still be in the dark as to much of our work. This much is 
positive: osteopaths have time and again apparently cured grave val- 
vular lesions; cases that eminent speciahsts diagnosed as absolutely or- 
ganic lesions. Our practitioners have ehminated the murmurs, reduced 
the size of the heart, and removed any and all systemic symptoms. These 
patients are well, have been well for years, and are leading active fives. 
But were these cases suffering from organic lesions? No doubt there 
was valvular leakage, hypertrophy and dilatation, but was the valve 
defect a functional one? In other words, was it due to strain and dis- 
tortion? In ah probabifity the patients' days were numbered and post- 
mortems would have shown grave lesions and quite likely more or less 
organic changes. 

Does it not seem likely that some functional lesions may terminate 
in organic lesions? Through continued stretching of the valves and their 
immediate tissues, fatty degeneration may take place; the same as fatty 
degeneration of the heart muscle, occurring in dilatation of the cham- 
bers. If we can remedy functional lesions through specific work upon 
nerve centers and fibers, why cannot we influence organic lesions and at 
least reduce the gravity to a minimum? We know functional diseases of 
the heart, as palpitation, rapid heart, slow heart, etc., can be corrected, 
and from all indications, functional valvular leakages are generally easily 
and quickly remedied; it is only a step farther to affect truly organic 
lesions. The same valves, the same nerves, and the same osteopathic 
lesions are noted. Then it is only a continuation of the same process 
from functional disease to organic disease. Indeed, no one is able to 
draw a line between the two. Probably, as was intimated before, careful 
osteopathic treatment in rheumatism and other diseases that are apt to 
predispose to heart affections, will keep the heart so strong functionally 



The Practice of Osteopathy 653 

and organically that resulting valvular lesions are not nearly so likely to 
develop. The heart can be treated and controlled as can any tissue or 
organ. It certainly stands to reason that osteopathic therapeutics is 
rational in both preventing and curing valvular lesions. The M. D. gives 
liis drugs with the hope of maintaining heart muscle integrity, of lessen- 
ing a too forceful beat, of increasing waning power, of promoting general 
circulation, of preventing and lessening complications. We can do the 
same thing with our methods, even more effectuallj^, and with no prob- 
abihty of harmful effects. 

It would appear there are at least two ways in which organic lesions 
may develop. First, as stated above, through functional distortion, 
the normal heart muscle being strained from severe exercise, or a weak, 
flabby, or disused heart muscle being overtaxed by ordinary exercise. 
Here it will be seen that in the first instance immediate rest will prob- 
ably correct the weakness; in the second, rest and general building up 
of the body if the atonic heart muscle resulted from some debilitating 
disease. If from local causes correction of the specific osteopathic lesion 
should be effective. 

Secondly, through strong and rapid heart action the valves are 
ruptured or lacerated, always at the point of maximum contact, 
and thus present a favorable surface to micro-organisms. 

Owing to the valves being a reduplication of the endocardium, they 
have no muscles or blood-vessels, so that in functional leakages, in- 
flammation does not play a part, hence, a possibihty of degeneration 
occurring from excessive stretching. 

The large majority of osteopathic lesions are unquestionably 
found in the upper five dorsal vertebrae and the first five or six ribs on the 
left side, although cervical lesions, in many instances, play an important 
secondary, if not the primary, role. These mal-adjustments affect 
vasomotor nerves to the heart, that is, to coronary vessels, the dorsal 
and cervical sympathetics, the vagi, and the phrenic. We are unable 
to state just how these lesions disturb nerve conductivity; what present 
anatomy and physiology teach us does not fully explain. Osteopathic 
dissection must be the means to the end of the explanation. We have 
many clinical results, but not the physiological knowledge, as yet, to 
support it. 

The dropping down of the first rib, as well as the clavicle, inter- 
fores with the large blood-vessels, especially the subclavian, and causes 
increased resistance of the heart's action and probably a certain regurgi- 
tative effect. This regurgitative effect would also occur in cases of ob- 



654 The Practice of Osteopathy 

struction to the aorta by constriction of the diaphragm from dropping of 
the floating ribs. To what extent this latter feature has been demonstrated 
is not known. In valvular diseases it is practical to divide them for 
treatment into, ftrst, where the lesion is compensated; second, where 
compensation is incomplete; third, where compensation is lost. 
With all cases we should give consideration to environment, tempera- 
ment, habits, food, clothing, exercise, etc. Often these secondary mat- 
ters are of vital importance, especially when compensation is failing. 
The Schott method of treatment may be of some avail; this treatment, 
which is composed of a series of resistant exercises, tends to lessen per- 
ipheral resistance, develop heart muscle, and remove heart stasis. 

Speaking in general, hypertrophy and dilatation follow valvular 
leakage, as a secondary effect. It is a compensatory condition, and 
whenever compensation is failing, there is natiu'ally a breaking down of 
the structural tissues of the heart; that is, the muscular hypertrophy 
is losing in integrity. Our primary aim, then, should be to keep up the 
compensation, which is represented in the hypertrophy, although there 
are cases that fail rapidly, especially in emphysema and cirrhosis of the 
lungs. Generally, in hypertrophy and dilatation, there is a dispropor- 
tion between the amount of work the heart has to do and its ability 
to do it. One of two things has occurred ; there is an increase in peripheral 
resistance or the volume of blood through the heart is abnormal in quan- 
tity\ Loudon^ says: "The treatment of chronic disease of the heart 
requires a longer time, as a rule, than the same disorder in the acute stage. 
Some cases cannot be materially helped; a vast majority may be greatly 
benefited after a thorough trial; while more than we might at first sup- 
pose, can be entirely cured. We desire to quote at length from Hare 
relating to this point. He says: 'A chronic structural change in the 
heart resulting from an acute process is not always synonymous with 
chronic heart disease. Thus, acute endocarditis occasions a variety 
of changes of the mitral and aortic valves which long may indicate their 
presence by their characteristic murmurs, and yet in time these may 
wholly disappear. That many such cases outgrow the valvular trouble, 
especially mitral lesions, there can now be no doubt. The majority, 
even of those in whom valvular murmurs permanently continue, do not 
have their health unfavorably affected for years, and in many of these, 
the duration of life is not appreciably shortened.'" This statement, 
from such an author, gives the osteopath great encouragement; for add 

1. Valvular Heart Diseases, A. O. A. Journal, March, 1905. 

2. Journal of Osteopathy, February, 1904. 



The Practice of Osteopathy 655 

to those above referred to, which recover in time from all valvular trouble, 
the many cases of valvular insufficiency, due to dilatation, owing to os- 
teopathic lesions to the trophic nerves, and which may be cured by re- 
moving such lesions, we find that quite a percentage of cases are thus 
disposed of. 

''It is doubtless true, also, that the cases above mentioned having 
valvular thickening and vegetations, could have been cured in quicker 
time and greater number had osteopathic treatment been given to tone 
the heart, upbuild the general circulation and increase the activities of 
the excretory organs. The importance of the lungs is often overlooked 
in the treatment of cardiac diseases. The osteopath's abihty to expand 
the chest and increase the capacity of the thorax should be demonstrated 
in both cardiac and pulmonary troubles. It is said to be a universal 
law throughout the animal kingdom 'that muscular power is directly 
proportional to the amount of oxygen consumed.' Hence give the power, 
and have your patient live as much out of doors as practicable. Exer- 
cise should be moderate and always stopped short of fatigue." 

Treatment of the abdominal organs should not be neglected, for 
improved circulation here and thorough removal of effete products will 
influence the heart. Freedom from worry, strains, etc. are essential. 
Tepid baths are best. 

A person may have a valvular leakage and not be aware of it. Prob- 
ably it is best to inform them, except in certain neurotic individuals. For 
then they can take special care of themselves, as to overwork, strains and 
intercurrent infections, and their life and usefulness be greatly prolonged. 

When compensation begins to break, certain symptoms are noticed, 
as heart irregularitj^, difficult breathing, particularly at night, shortness of 
breath, and more or less anemia. Later there is disturbance of rhythm, 
cyanosis, dilatation of heart and dropsy. Frequently, considerable can 
be accomplished through the upper dorsal treatment, attention to the 
chest mobility, manipulation of the abdominal organs and diaphragm, 
and special attention to the diet, rest and some exercise. A light gen- 
eral treatment will assist the labored circulation and improve assimila- 
tion, and a change of climate may be of benefit. 

Hypertrophy of the Heart 

Hypertrophy of the heart is an enlargement of the heart, due to an 
increase in the muscular tissue. It is usually associated with dilatation. 
The ventricles are more often involved than the auricles, and the left 
ventricle is more likely to be affected. 



656 The Practice of Osteopathy 

Etiology. — Valvular disease of the heart causing an obstruction 
to the outflow of blood, as mitral insufficiency, diseases of the aortic 
valve; increased intra-vascular pressure, caused by sclerotic changes in 
the walls of the vessels; contraction of smaller arteries, due to irrita- 
tion of toxic substances in the blood, as in Bright's disease. Overeating 
or drinking and excessive physical exercise would also induce hyper- 
trophy of the left ventricle. Hypertrophy of the right ventricle is caused 
by valvular lesions on the right side. Lesions of the mitral valve caus- 
ing an increased resistance in the pulmonary vessels are etiologic factors; 
also diseases of the pulmonary vessels in the lungs, as in cirrhosis and 
emphysema. There are conditions affecting the heart, as the use of 
tea, alcohol and tobacco. Disturbed innervation, as in exophthalmic 
goiter; derangements of the vertebrae, and ribs corresponding to the 
upper five dorsals; downward displacements of the floating ribs, causing 
a prolapse of the diaphragm and a consequent retardation of blood 
through it to and from the heart, will affect the heart's action. Simple 
hypertroph}^ never occurs in the auricles; it is always accompanied with 
dilatation. The condition develops in the left auricle in mitral lesions; 
in the right auricle when there are disturbances of the pulmonary circu- 
lation. The tiicuspid is rarely affected primarily. 

Pathologically, the left side of the heart is more commonly en- 
larged than the right; the ventricles than the auricles. The shape of 
the heart varies when the left ventricle is hypertrophied, the conical 
shape being more or less lost; it lies more horizontally and is elongated. 
When both ventricles are enlarged the heart is round. When the right 
ventricle is ajffected, it occupies the largest part of the apex. The in- 
crease in the size of the heart is probably due to a numerical increase in 
the muscle cells. The muscle is firm, of deep red color and cuts with 
considerable resistance. Normally, the heart weighs from eight to 
nine ounces. In general hypertrophy it may weigh from fifteen to thirty 
ounces. 

Symptoms. — Hypertrophy, being a conservative process or an 
act of compenatlon, does not necessarily present any symptoms at 
first. At the beginning there is rarely any pain, but a sense of fullness 
and discomfort is present. As the hypertrophy increases, the arteries 
become fuller, the veins less full and the circulation accelerated. In hyper- 
trophy associated with arteriosclerosis the blood pressure is increased, 
and the pulse full and firm. Epistaxis may be of frequent occurrence 
and the face congested. Pains occur in the precordial region. There 
are nervousness, headache, hot flushes, palpitation, cough and vertigo. 



The Practice of Osteopathy 657 

In hypertrophy of the left ventricle, the apex is lower and to the left. 
The carotids pulsate visibly and the radial pulse is strong and tense. 
Percussion reveals enlargement to the left and downward. The first 
sound is louder and prolonged. The aortic second sound is intensified. 
In hypertrophy of the right ventricle the enlargement is to the right 
edge of the sternum. The second sound in the pulmonary area is in- 
creased. The apex-beat is displaced outward. The pulse at the wrist is 
usually small. Hypertrophy of the auricles always occurs with dila- 
tation, which is most common in the left auricle. The physical signs 
are characteristic. They are caused by diseases of the mitral and tri- 
cuspid valves and diseases of the lungs, as emphysema and cirrhosis. 

Diagnosis. — If a careful examination is made, hypertrophy can 
hardly be mistaken for any other condition. There may be a resem- 
blance to pericardial effusion, pleuritic effusion, aneurism or mediastinal 
tumor, when near the heart. The X-ray v/ill be of assistance. 

Prognosis. — Depends largely upon the cause producing the hyper- 
trophy. Remember that hypertrophy is a compensatory act. The 
prognosis is more or less unfavorable if resulting from emphysema, 
Bright's disease or in old age ; also in degeneration of the vessels. In most 
cases of functional overaction, persistent treatment can usually ac- 
complish considerable. 

Treatment. — The treatment must be according to the cause of 
the hypertrophy. There are many etiological factors, consequently the 
treatment depends upon the influence of these factors. The principal 
treatment will be found under endocarditis, as valvular diseases are 
usually caused by endocarditis, and hypertrophy of the heart is a con- 
servative process of nature — an act of compensation secondary to valvu- 
lar and arterial lesions. The indications are to lessen the force and 
number of pulsations of the heart and remove the cause if possible. 

Dilatation of the Heart 

There may be dilatation with thickening of the walls, and dilata- 
tion with thinning of the walls, or they may be normal. It may be produc- 
ed by impaired nutrition of the cardiac muscle or increased endocardial 
tension. More frequently the two conditions act jointly, although they 
may act singlj^ Impaired nutrition of the cardiac muscle ma}^ diminish 
the resisting power and thus cause dilatation. Weakening of the cardiac 
walls may occur in scarlatina, typhoid, typhus, rheumatic fever, etc. 
It is met with in chlorosis, anemia and leukemia. Increased endo- 
cardial tension occurs in sudden, extreme exertions and in valvular dis- 



658 The Practice of Osteopathy 

eases. A normal heart through excessive exertion is rarely if ever di- 
lated. The important causes are considered under hypertrophy. Both 
impaired nutrition and increased endocardial tension are influenced di- 
rectly by the extent and severity of the osteopathic lesion. This point 
has been considered under chronic endocarditis. 

Pathologically, the right side is more commonly affected than the 
left. In advanced aortic incompetency, all the divisions may be dilated. 
When one ventricle alone is dilated the septum may be seen to bulge. 
In extensive dilatation, the auriculo-ventricular rings are often dilated. 
Other orifices may also be dilated. The condition is often associated 
with hypertrophy and fatty degeneration. The muscle may be nor- 
mal in appearance. The endocardium is often opaque, and roughened 
in patches. There is degeneration of the ganglia of the heart. 

Symptoms. — Dilatation causes weakness of the walls of the heart, 
but as long as the hypertrophied walls can compensate, no symptoms re- 
sult. When the hypertrophy weakens, greater dilatation occurs and 
symptoms of venous stasis appear, as dropsy, feeble irregular pulse, 
dyspnea, cough and scanty urine. In some instances there may be brief 
precordial distress, faintness or palpitation. 

Physical Signs. — On inspection the apex-beat is diffuse and feeble, 
or it may not exist. As observed by Walsh, the impulse may be visible 
and yet not palpable. Palpation — the impulse is diffuse, feeble and 
fluttering. The pulse is small, rapid and irregular, rarely is it slow. 
Percussion — the area of lateral dullness is increased to the right. There 
is increase in the dullness downward to the sixth interspace and upward 
to the second rib in many cases. Auscultation — the sounds are weak 
and sharp. The first sound is shorter, lacks its muscular element and 
becomes more like the second. The sounds are obscured, the cardiac 
murmurs are present. In many cases the characteristic gallop rhythm is 
present. When the right heart is chiefly dilated, the true apex-l^eat 
cannot be felt, while an impulse may be felt below the xiphoid cartilage, 
and a wavy impulse is seen in the fourth, fifth and sixth interspaces to 
the left of the sternum. 

Diagnosis. — When a clear history can be obtained, together with 
the characteristic features, the diagnosis can be readily made. Prog- 
nosis depends upon the cause. 

Treatment. — The treatment of dilatation is that of valvular heart 
disease. It is important that the patient should have plenty of rest, 
suitable food and regulated exercises. 



The Practice of Osteopathy 659 

In acute dilatation absolute rest is necessary. Limit the fluid in- 
take, and open the bowels thoroughly. In serious cases, bleeding, a 
pint or more, should be considered. 

Myocarditis 

Myocarditis is an acute or chronic inflammation of the heart mus- 
cle. In many cases where the muscle substance of the heart is diseased, 
there is no doubt that osteopathic lesions are potent underlying fac- 
tors. The lesions lessen nervous integrity and thus have a direct bear- 
ing upon the muscular strength and the hkelihood of inflammatory in- 
vasion. 

Acute Interstitial Myocarditis. — This affection is met with in 
fevers, in connection with endocarditis and pericarditis. Of the infec- 
tions diphtheria and typhoid are the most frequent. Septic emboli may 
block the coronary arteries in pyemia, septicemia and mahgnant endo- 
carditis and cause infarcts in the myocardium with abscess formation. 
It may be a comphcation of gonorrhea. Males are affected more often 
than females. 

Pathologically, in acute interstitial myocarditis the changes 
take place in the intermuscular connective tissue. This becomes swollen 
and round-cell infiltration takes place. The muscle substance is pale 
and soft. Acute parenchymatous degeneration is characterized 
by degeneration of the muscle fibers, which are infiltrated with gran- 
ules. The carchac muscle throughout is pale and soft. Acute suppu- 
rative myocarditis is a rare condition. In this form abscesses occur, 
which vary in size from a pin's head to a pea. They vary greatly in 
number and are usuafly multiple. They may not cause any disturbance 
and may not be recognized before death. On the other hand the abscess 
may rupture into the heart cavities or the pericardium, or it may per- 
forate the intraventricular septum, thus allowing the venous and ar- 
terial blood to intermingle. It may cause a cardiac aneurism. 

Symptoms. — These are very uncertain. If during the course of 
any of the causal diseases, the pulse suddenly becomes rapid, small and 
irregular and compressible and palpitation and syncope develop, all of 
which point to cardiac weakness, myocarditis may be suspected. Signs 
of venous stasis develop later in the affection. The physical signs are 
those of dilatation. This is extremely grave. Cases do, however, re- 
cover. 

Treatment. — The treatment is the same as that given under endo- 
carditis and pericarditis. Rest in bed is absolutely necessary. Pay 



660 The Practice of Osteopathy 

particular attention to the nourishment and to the h3'gienic surround- 
ings of the patient. Especially attention should be given to the upper 
dorsal area, both to the muscles and the interosseous lesions, for this 
influences cardiac muscle innervation and nutrition. Then lesions of the 
upper cervical are important owing to their relationship to the vagi 
which control muscular impulses of the heart muscle. 

Chronic Interstitial Myocarditis. — Among the causes of this 
form of myocarditis are the excessive use of tobacco or alcohol; gout, 
rheumatism, malaria, diabetes, chronic nephritis, syphilis and lead pois- 
oning. Acute interstitial myocarditis may lead to the chronic form. 
This form is "commonly caused by the narrowing of a coronary branch 
in a process of obliterative endarteritis" (Osier). It may be due to in- 
juries of the anterior and lateral portions of the chest. Unquestionably 
osteopathic lesions of the upper dorsal vertebrae and ribs and cervical 
region affect the integrity of the heart muscle and predispose to conges- 
tion, inflammation and debility of the tissue. Males of middle life are 
more predisposed to chronic myocarditis. 

The pathological changes occur most frequently in the left ven- 
tricle and the septum, but they may occur in any portion. The patches 
and streaks that are in the walls are sometimes only seen upon very 
careful examination. They are of a gray or grayish white color, and 
when fibers that have undergone fatty degeneration are intermingled, 
they have a grayish yellow tint. The condition may be associated with 
hypertrophy and dilatation. A part of one of the heart cavities may be- 
come dilated, producing what is known as cardiac aneurism. There is 
destruction of the muscular fasciculi with subsequent development of 
new fibrous tissue. Fatty degeneration is also seen. 

Symptoms.— Advanced fibroid myocarditis may be present with- 
out any s3Tiiiptoms. Slight degrees present no symptoms. The symp- 
toms when present are: a feeble, irregular, slow pulse; attacks of angina 
pectoris and sometimes arhythmia. The blood pressure is increased. 
Upon exercising there is more or less pain, cardiac distress and dyspnea. 
If fatty degeneration is also present the pulse wifl ])e quickened and ir- 
regular. 

Diagnosis. — This is often very difficult and it requires careful and 
persistent study of a case to be able to make a correct diagnosis. 

Prognosis. — This is grave, though unquestionably a number of 
cases have been distinctly improved through osteopathic methods. Sud- 
den death is liable to occur at any time from complete obstruction to the 



The Pkactice of Osteopathy 661 

coronary arteries, as this condition is associated with sclerosis and nar- 
rowing of these arteries or their branches. 

Treatment. — The treatment of chronic myocarditis is largely in- 
cluded in chronic endocarditis. The cause of the disease should be de- 
termined, if possible. Careful treatment to the ribs of the left side, 
from the first to the sixth, and the corresponding vertebrse, will be 
of great aid in controlMng the disease. The cervical region demands 
attention, owing to the influence of the vagi on conduction of the heart 
impulse and to vasomotor effect. Attention should be given to the diet 
and hygiene of the patient. Outdoor life, bathing of the skin, and careful 
treatment of the vasomotor nerves will be of great help. 

Direct attention to the entire splanchnic region as vasomotor con- 
trol here materially lessens the work of the heart and assists generally 
in maintaining the digestive and nutritive functions. 

Degeneration of the Heart Muscle 

In fatty degeneration, the sarcous substance of the fasciculi is con- 
verted into fat. In fatty overgrowths there is an excess of fat in and 
about the heart. 

Fatty degeneration is ver\^ common and is due to an interference 
with the nutrition of the cardiac muscles. It is found in the impaired 
nutrition of old age, of cachectic states, of grave infectious diseases and 
of wasting diseases. In poisoning by arsenic and phosphorus, intense 
fatty degeneration is produced. Pericarditis may be associated with 
changes in the superficial layers of the cardiac muscle. Lesions of the 
coronary arteries will produce this condition; also impairment of the 
oxygen-carrying power of the blood. It occurs most frequently in men 
after forty years of age. The affection may be either general or local. 
It is most commonly seen in the left ventricle. When the condition is 
general the heart is dilated, flabby and relaxed. Microscopicafly, the 
muscular fasciculi exhibit a loss of nuclei, and oil drops and granules 
ui^pear in the fibers. The affection may be present without any notice- 
able symptoms. Slight degrees and localized fatty degeneration are 
unrecognizaljlc. Dilatation must be present to produce symptoms. 
This is apt to occur early. Dyspnea; asthma; cough; angina pectoris; 
diopsy; slow, weak pulse; palpitation, and toward the end, Chcyne- 
Stokes breathing may appear. Mental symptoms, such as maniacal 
delusions, may come on and last for weeks. Prognosis depends upon th(^ 
cause and extent of involvement. 

The treatment is largely that of tlilatation of the hearl. An cf- 



662 The Practice of Osteopathy 

fort must be made to determine the cause, and treatment should be ap- 
plied accordingly. Considerable can be done in improving the nutri- 
tion of the tissues of the heart by hygienic and dietetic measures. Light 
exercises will often be of aid, but care has to be taken that the exercises 
do not tax the patient too severely. A general treatment of the body 
will be a helpful measure in invigorating the system as a whole and ton- 
ing the cardiac tissues. The diet should be nutritious; largely nitro- 
genous. 

Raising the ribs over the heart and increasing the chest expansion 
will be of help in cases where there are attacks of dyspnea and angina. 
Many cases present deep seated lesions in the upper dorsal region. When 
there are attacks simulating apoplexy, lay the patient fiat upon the back 
with the head slightly elevated. 

Fatty overgrowth is associated with general obesity and sooner 
or later this infiltration impairs the nutrition of the cardiac muscle and 
true fatty degeneration results. This form occurs more frequently 
in men, and between the ages of forty and seventy j^ears. The charac- 
teristic changes consist of an increase in the normal fat. The heart may 
be enclosed in a thick covering of fat. The fat may also be deposited 
between the fasciculi, sometimes reaching the endocardium. Fatty 
overgrowth is certain to exist in extreme obesity. No symptoms are 
produced until the muscular fibers weaken so that dilatation occurs. 
The presence of extreme obesitj^ combined with signs of cardiac weakness, 
point to fatty overgrowth. The treatment of fatt}^ overgrowth of the 
heart is largely the same as that of obesity. Oertel's method of lessen- 
ing the amount of liquids, proteid diet and graduated exercises is effective 
in cases where heart compensation is intact. 

Neuroses of the Heart 

Palpitation is a more or less rapid action of the heart, of which the 
patient is conscious. There is usually an irregular or forcible action of 
the heart, as well as a frequency of the heart-beat. There is generally 
some local irritation to the cardiac nerves; especially are lesions found 
to the third and fourth ribs, although a lesion may be higher or lower in 
the dorsals or it may be in the cervical area. Muscular lesions are fre- 
quent. These lesions predispose to the disturbances of reflex stimuli, 
still the general health may be so weakened or the reflex irritation so 
pronounced that palpitation results independently of predisposing os- 
teopathic lesions. Females are more liable to be affected. The neurotic 
state is a common source of the disorder. If palpitation is long continued 



The Practice of OsTEOPATH-i 663 

it causes hypertrophy. It often occurs at puberty, during menstruation 
and at the climacteric period. Anemia, the acute infectious diseases, 
dyspepsia, disturbances of the ovaries and other pelvic organs are com- 
mon causes. The abuse of coffee, tea, alcohol, tobacco; diseases of the 
stomach, overwork, fright, grief, anxiety, and sexual excesses are causa- 
tive factors. Palpitation may be associated with organic diseases of the 
heart, but as a rule it is a purely nervous aiffection. 

The patient's perception of the increased action and force of the 
heart is the essential element in palpitation. The action of the heart 
varies greatly and at times it may be a mere fluttering which lasts but a 
few minutes. In severe cases the heart beats violently and the pulse may 
be rapidly increased and reach 160 or more. The face is usually pale, 
but may be flushed. The heart's action is not increased in some cases. 
The attack generally lasts only a few minutes. 

The first consideration in treatment is to locate the disturbing 
factor. Raising the ribs over the heart and lowering the first rib; cor- 
recting the clavicle in a few instances, or inhibiting along the upper dor- 
sal region will usually quiet the heart's action. Stimulation of the vagi 
nerves, as they pass along the side of the neck, may be all that is neces- 
sary; in some cases inhibition of the superior cervical sympathetic or of 
the middle cervical region, acting on the depressor nerve of the heart, 
will lessen the tumultuous action of the heart. It will be recalled that 
either there is irritation of the accelerator nerves of the heart or the 
vagus is inhibited. 

All reflex disturbances, as a displaced uterus, indigestion, etc., 
must be removed before the palpitation can be permanently stopped. 
Rest and confidence in the treatment are of great importance. A very 
few cases will require a hot bath and a general treatment and possibly 
an ice-bag over the heart to quiet the increased activity. In anemic 
cases hygienic measures and a proper diet, coupled with the treatment 
for anemia, are indicated. If the attack is severe, the patient should 
rest in a recumbent posture and drink something warm, besides re- 
ceiving the indicated treatment. When the patient is not a decided 
neu]-asthenic a rapid five or ten minute walk will often normalize the 
heart's action. 

Tachycardia is rapid action of the heart and commonly occurs in 
paroxysms. There are no heart sensations, as in palpitation. Either 
the sympathetics are stimulated or the vagus inhibited. It is not gener- 
nll\- I'clatcd to lesions of the heart, but is in reality a disorder of the 
nervous system. In some instances the condition is physiologic. 



664 The Practice of Osteopathy 

Nervous strain, in the form of osteopathic lesions to the upper dorsal 
or cervicals irritating the S3mipathetic, is the most common cause. Emo- 
tion, fright and severe exercise are other causes. It is found in neures- 
thenia, anemia, hysteria and in those using an excessive amount of to- 
bacco, tea and coffee. Reflex stimuli from abdominal or pelvic dis- 
order, especially during the climacteric may induce tachycardia. In 
exophthalmic goitre the sympathetics are overstimulated, and in some 
instances the vagus inhibited, leading to "heart hurry." Tumors, 
hemorrhages, enlarged glands, etc., obstructing the action of the vagus, 
are a source of rapid heart. 

Sudden onset with rapid action of the heart, small weak pulse, head- 
ache, flushed face and faintness are common symptoms. 

The treatment is somewhat similar to that outHned under palpita- 
tion. Locating the cause is the first essential. Besides removing local 
osteopathic lesions, inhibition to the cervical and dorsal sympathetics 
is effective. Raising the ribs over the heart will lessen the pulse-rate. 

Rest, diet and general care of the patient may be necessary. Out- 
door exercise and cold bathing are beneficial. In a few cases springing 
the dorsal spine forward, raising the floating ribs, and slight traction of 
the cervical spine are effective in slowing the heart's activity. A few 
cases are very refractory, especially in neurotics. 

Brachycardia, or slow action of the heart, is the opposite of tachy- 
cardia. In a few cases it is physiologic. It usually occurs secondarily, 
following infectious diseases; accompanying nervous disorders, as hys- 
teria, melanchoha and neurasthenia, and is associated with diseases of 
the digestive organs, pulmonary disorders and toxic effects of coffee, tea, 
tobacco, and drugs and the toxins of jaundice, diabetes, uremia, etc. 
Obstructions to the cervical sympathetics and irritations of the vagus, 
from osteopathic lesions, may be either direct causes in themselves or 
predisposing factors in the above diseases. 

A slow, iveal< pulse is the characteristic symptom. The heart 
sounds are feeble. When the pulse beat is below sixty per minute it is 
diagnostic. 

In the treatment of slow heart, as in the other neuroses of the 
heart, the cause should be first determined. A stimulating treatment to 
the cervical sympathetics and inhibition to the pneumogastric will readily 
reheve many cases, at least temporarily. The lesion may be directly to 
these nerves and of course removal of the same is essential. Inhibition 
of the pneumogastric probably affects the activity of the depressor nerve, 
and stimulation of the cervical sympathetics, besides acting on the ac- 



The Practice of Osteopathy 665 

celerator fibers of the heart directly, influences the blood supply of the 
body and thus increases arterial tension. Stimulation to the upper 
chest anteriorly and posteriorly, over the cardiac region, will increase 
the rapidity of the slow heart. Rest and care of the general health is 
necessary. 

Arhythmia, or an irregularity of the heart's action and pulse beat, 
often due to lesions in the cervical region interfering with the vagi, sym- 
is pathetic or vasomotor nerves to the heart. In a number of cases the 
first, second or third rib on the left side is at fault and a correction of 
it will relieve the irregularity immediately. It is claimed that there are 
nerves at the fourth and fifth dorsals that tend to control the rhythm of 
the heart-beat. Other causes are organic diseases of the heart and 
nervous system, reflex disturbances, excessive use of tobacco, coffee 
and tea. 

"Normally, the contraction of the heart originates at the sinoauricu- 
lar node, at the mouth of the superior vena cava, is conducted to the 
auricle, and thence to the ventricle by way of the auriculo-ventricular 
bundle (bundle of His or Gaskell's ridge). Under conditions of abnor- 
mal stimulation, contractions may originate in the auriculo-ventricular 
node in the wall of the right ventricle near the coronary sinus ; or in the 
auriculo-ventricular bundle on the ventricular side of the node; or in the 
auricular tissue itself." — Clinical Osteopathy. 

Fibers from the right vagus pass to the sinoauricular node, and from 
the vagus to the auriculo-ventricular bundle. Lesions of the upper 
three cervicals may readily disturb the vagi through circulator}^ and 
chemical sources as well as through the communicating branch of the 
second spinal nerve. Thus the rhythmic power of the heart, rate and 
strength, and conductivity of impulse may be readily influenced, which 
is borne out by clinical experience. 

There are several forms of irregular heart action. For a description 
of same it is probably best to refer the student to special works. ^ 

The more common forms are Sinus Irregularities, the Extrasystole, 
Paroxysmal Tachycardia, Auricular Fibrillation, Auricular Flut- 
ter, and Heart-block. Pulsus Alternans is a rare form, and is of 
•iiavc significance when the heart muscle is degenerated. A knowledge 
oF auricular bbrillation is of special value, for it is a common form 
and often indicates a serious condition. 

Most of the irregularities are not of special pathological importance, 

1. Mackenzie, Diseases of the Heart; Lewis, Mechanism of the Heart Beat; 
Macleod, Physiology and Chemistry in Modern Medicine. 



666 The Practice of Osteopathy 

providing the heart muscle is healthy. They are best studied through 
instrumental means and require considerable experience in order to de- 
termine the exact condition. 

Frequently, unnecessary worry has been the result in discovering 
irregulartities in the young as well as in otherwise healthy adults. Only 
when the cardiac muscle is diseased or degenerated through various 
infections and toxi-^ properties in the blood should they receive unusual 
attention. 

Dorsal and lower cervical lesions that affect the heart by way of 
the sympathetics no doubt distui'b nutrition of the heart tissues. And 
lesions of the vagi, particularly of the upper three cervicals, will dis- 
turb the rhythm, rate, strength, and conductivity of the impulse through 
auricles and ventricles. In no other organ of the body will the osteo- 
path be better rewarded for careful and painstaking work than in nor- 
malizing the stimuli from syinpathetic and vagi that influence the heart. 
Stimulatory and inhibitory efforts will frequently suffice, but in our 
judgment it is always better to secure interosseous adjustment if possible. 

Though a number of individuals with heart irregularities are of a 
neurotic type, that predisposes to nervous disturbances of various kinds, 
still it would be an interesting study, especially in cases of children, to 
note what percentage are the result of upper cervical lesions caused by 
birth injury. 

Angina Pectoris 

Angina pectoris is characterized by pain in the cardiac region 
which usually extends to the inner side of the upper arm and forearm. 
"This region corresponds to the peripheral distribution of the lower 
cervical nerves (6th and 7th in the arm) and the upper three or four 
dorsal nerves (in the upper arm and the chest). "^ Occasionally similar 
areas of the right side are affected, and in a few there is pain in the lower 
jaw and back of the ears. "The starting of the pain is usually across the 
chest, about the level of the third ribs, or as low as the fifth ribs," al- 
though the inception may be anywhere in the left chest or the arm. The 
duration of the pain is from a few seconds to several minutes; some- 
times it may remain for several hours. 

Osteopathic lesions are invariably found in the upper dorsal, in- 
cluding ribs, or lower cervical region, which are predisposing factors that 
tend to exhaust and weaken the cardiac muscle, and disturb the coro- 
nary circulation, so that resistance is lowered. Thus toxic agents and 

1 . Mackenzie, Oxford Medicine, Vol. II. 



The Practice of Osteopathy 667 

infections may readily involve the cardiac tissues. Many cases present 
more or less arteriosclerosis, which involves the heart and affects its cir- 
culation. Inflammation of the root of the aorta from syphilis is a fre- 
quent cause. Valvular heart disease and chronic nephritis are other 
underlying factors. Worry, strenuous hving, and continued physical 
strain are to be considered. There are a group of cases, that are com- 
paratively mild and frequently found in women, that are of toxic origin, 
due to intestinal stasis as a result of constipation, adhesions, etc. The 
ileocecal section is commonly involved in these instances. Focal infec- 
tions may be an exciting cause. 

The osteopathic lesions undoubtedly affect the cardiac innerva- 
tion, particularly vasomotor and trophic, thus leading to consequent 
disturbances of cardiac circulation and resulting irritation to the ganglia. 
Sclerosis and spasm of the coronaries, ischemia, cramping, exhaustion, 
and degeneration of the heart muscle, and cardiac neuralgia, are various 
results that may take place. 

The paroxysm usually begins suddenly, often during exertion or 
intense mental emotion. The pain is agonizing and of a grip-hke char- 
acter, and there is a feeling of impending death. The intercostal mus- 
cles are constricted and there may be a feeling of suffocation. The 
pains radiate up the neck and down the arm, and may be accompanied 
by numbness or tingUng. There is usually extreme pallor, and the skin 
is ashen. vSweating is not uncommon, and dyspnea may be present. 
The attacks occur at intervals, varying from a few days to many years. 
After the paroxysms there is instant relief. 

Other cases may present less severe attacks. 

In the diagnosis the only condition with which true angina pectoris 
is liable to be confounded is pseudo-angina pectoris. Pseudo-angina 
or hysterical, angina occurs chiefly in women or in neuresthenic men. 
These cases are often excited by toxemia. The attack usually occurs at 
night and is unassociated with organic heart disease. There is a feeling 
of cardiac distention instead of constriction as in true angina. There 
is emotional excitement and the attack lasts one or two hours, which is 
usually longer than that of true angina. The prognosis is unfavorable, 
although many cases live for a number of years. A few cases have re- 
covered under a thorough course of treatment. 

The treatment of angina pectoris consists in correcting the dis- 
ordered upper dorsal vertebrae, the upper left ribs over the heart, and the 
lower cervicals. Invariably lesions are found in this region and if the 
treatment is applied to correct these disorders, the attack can frequently 



668 



The Practice of Osteopathy 



be relieved. By following up the treatment during the intervals, a num- 
l^er of eases can be practically cured. A common lesion found is a slight 
lateral curvature in the upper dorsal region. This curvature is often- 
times great enough to cause a sul^dislocation of several of the ribs, wliich 
certainly complicates the derangement, at least as far as a quick cure is 
concerned. 

During the attack raise the ribs over the heart at the point of con- 
striction so as to relieve the impinged nerve fibers. Hot drinks are of 
value. The vagi and phrenic nerves may also be at fault in some cases. 
The sensory nerves to the heart are from the first, second and third dor- 
sals. 

Ice-bags or heat applied locally will be a helpful measure. In cases 
where there is high arterial tension, an inhibitory treatment to the upper 
and middle cervical regions will be of special aid, as it relieves this ten- 
sion by affecting the vasomotor nerves. This treatment will at least 
overcome the vasomotor form of angina pectoris. Hot foot-baths and 
friction will also be found of value. In many cases under forty or forty- 
five syphilis is a cause. In cases past middle life there is often organic 
disease of the circulatory organs. 

The patient should at all times avoid any excitement and live a very 
quiet life. He should take frequent vacations. He should take the best 
of care of himself and his food should be nutritious. In pseudo-angina 
the treatment is to relieve the irritation to the nerves affected as well as 
the underlying affection. 



The Practice of Osteopathy 669 

DISEASES OF THE ARTERIES 

Arteriosclerosis 

(Atheroma) 

This is a thickening of the intima of the arteries, due to an inflam- 
matory increase of the connective tissue, associated with more or less 
fatty degeneration and calcification. 

Old age, alcohol, lead, gout, syphilis, rheumatism and other infec- 
tions, laborious work, overeating, nephritis, and calcareous water tend 
to produce the condition. Excessive eating and drinking are common 
causes of both atheroma and chronic renal diseases and should always 
be regulated. Physical overwork, chronic intoxications, etc., produce 
hypertension of the vascular system and thus lead to changes of the 
vessel walls. A rigid spine is invariably found; this may be a causative 
factor in itself, or an associated condition. All of the above list of causes 
are important. 

Pathologically, the arteries are thickened, tortuous and rigid. The 
intima may be occupied by rough, calcareous plates. In extreme cases 
the sub-endothehal tissue undergoes degeneration and breaks down in 
spots, forming "atheromatous abscesses." The disease may be cir- 
cumscribed or diffuse; in the latter there is a widespread distribution 
of the affection. Owing to the general effect, the heart, liver and kid- 
neys receive less blood and tend to atrophy. Microscopically, there is 
found more or less fatty degeneration of the different coats, and an over- 
growth of connective tissue in the intima. The arteries most frequently 
affected are the aorta and coronary. 

Symptoms. — Circulatory. — There is a high tension pulse and 
accentuation of the second aortic sound. There is also dyspnea, severe 
pain in the left side, palpitation, "pallor, and the left ventricle is hyper- 
trophied. Cerebral. — Such symptoms as headache, tinnitis, aphasia, 
vertigo, sjmcopal or epileptiform attacks may be present. Renal. — 
There is an increase in the quantity of urine, which is of a pale color and 
low specific gravity; at times it is albuminous. The disturbance leads to 
atrophic nephritis. There may be gastro-intestinal symptoms, as consti- 
pation, pain, etc., due to hardening of the splanchnic vessels. In some 
cases the peripheral arteries become obliterated. The veins l^ecome 
liard(Miod. 

Sequelae are cardiac dilatation, heart failure, paralysis, apoplexy, 
fatty heart, aneurism, contracted or senile kidney, angina pectoris, and 
in extreme cases, gangrene of the extremities. 



670 



The Practice of Osteopathy 



Diagnosis. — The characteristic symptoms are hardened arteries, 
high tension of the pulse, hypertrophy of the left ventricle and accen- 
tuation of the aortic second sound. The average blood pressure is from 
160 to 180 mm. of mercur}^, though it may be considerably higher. 

Prognosis. — Many cases can be greatly benefited by osteopathic 
treatment, and at the incipiency the improvement is generally marked. 
It usually runs a very chronic course. 

Treatment. — The treatment must necessarily consist, principally, 
in the removal of such conditions as are producing the degeneration. 
The rigid spine should be carefully treated by methods (preferably trac- 
tion) that overcome the contractures and release the intervertebral discs. 
The dorsal and lumbar areas, and the abdominal organs should receive 
special attention. Out-door fife and plenty of rest are important. Al- 
cohohsm, gout, rheumatism, syphihs, etc., must be remedied before 
there can be much change in the arteries. Freeliving and all excitement 
must be stopped. The patient's cooperation is invaluable. A milk 
diet is often beneficial. Besides treatment of the primary disease, a 
general treatment will be of much avail in equahzing and reducing arteria 
tension. Brunton^ speaks of cases of atheroma being cured by exercise 
and manual treatment to the rheumatic joints themselves. One, appar- 
rently suffering from senile dementia, was much improved after two years 
of this treatment apphed to the joints, and showed benefit to the 
cerebral circulation. The bowels and kidnej^s should be kept active, 
and the general health of the patient carefully watched. Keeping the 
skin active by daily baths is an essential factor in the treatment. Very 
frequently the disease is not only retarded, but improved. In high 
blood pressure venesection may be of benefit. 
1. Lectures on the Action of Medicine, p. 343. 



The Pkactice of Osteopathy 671 

DISEASES OF THE BLOOD 

By Earl R. Hoskins 

General Considerations: — It has been said that each individual 
is a part of all the generations which have preceded him. In the same 
way it might be said that every drop of our blood is a part of every other 
cell in our bodies. The other tissues are able to maintain their existence 
only through the ministrations of the blood and in turn the blood derives 
its own substance from tissues which it suppUes. We are accustomed 
to speak of certain organs as being those of blood formation, yet it is 
true that every tissue furnishes its quota of blood composition, making 
up the mass which we call blood. 

It is in one way an algebraic sum of good and baneful substances, 
without which there can be no normal function, and sometimes being 
of itseh a menace as well as an aid to other tissues, as in sepsis. There 
can be no perverted function of any tissue without there being a direct 
effect upon the blood. We may not always be able to measure this 
effect with our present laboratory methods. We may not be able to 
detect clinically the result of this alteration of the blood stream because 
of compensatory influences, dilution, phagocytic action, enzymatic action, 
oxidation, and the intricate processes of excretion. It must also be re- 
membered that normal blood is not of a certain definite chemical or phys- 
ical composition. It miist vary from minute to minute according to the 
normal metabolic phenomena which make up our succession of events 
associated with life. 

But comparatively Httle is known about this most important fluid. 
We have accumulated data regarding morphology and relative numbers 
of its formed elements and their behavior when sufficient abnormality 
is present to upset their wonted balance of arrangement. We have an 
ever widening field of investigation in the blood plasma in which we are 
constantly being told of newly discovered complexities. Certainly the 
field of the unknown is big enough to contain our unexplained blood 
reactions. 

It is probable that as our knowledge increases our number of 
diseases really considered as true blood diseases will decrease and be 
shown to be the effect of blood passing through certain pathologic tis- 
sues of the body. We can measure the number and proportion of formed 
elements, and the relative efficiency of the erythrocytes by the amount 
of hemoglobin which they carry. The genesis of the formed elements 



672 The Practice of Osteopathy 

is to be kept in mind in considering therapy. The erythrocytes and gran- 
ular cells developing in adult life, principally from the red marrow, leads 
our attention in decrease or increase of these particular cells to the great- 
est aggregation of red bone marrow which happens to be in the ribs. 
The anatomical relation of the ribs to the spine would seem to render them 
verj' liable to disturbances of nutrition and nerve control as a result of 
structural maladjustment and clinically this presumption is verified. 
Limitation of the motion of the thoracic spine is perforce accompanied by 
costal inactivity with disuse effects upon the red marrow and eventually 
upon the i-elative content of the blood stream. 

We can measure the efficiency of the erythrocytes in carrying oxygen 
to the tissues by measuring the relative amount of hemoglobin which 
a given volume of blood contains. The actual changes taking place in 
blood character are often thus sufficiently indicated for us in terms of 
our present methods of examination, to at least aid in the arrival at a di- 
agnosis. We sometimes have to remember that the adaptation to abnor- 
mality may be efficient enough to keep the apparent significance from tell- 
ing the " whole truth. " 

The Anemias 

The class of diseases which are referred to as the Anemias are those 
in which there is an actual, or apparent, decrease in the oxygen carrying 
element or hemoglobin. This may not be due to an actual decrease in 
amount of hemoglobin, but rather to a decrease in the ability of the red 
cells to carry it. This decrease in abihty may be due to alteration in the 
erythrocytes themselves, or to effects of change in the molecular concen- 
tration of the plasma in which they are suspended. The plasma may also 
contain certain poisons probably protied, which may make impossible 
the efficient carrying of hemoglobin by the erythrocytes. 

The simplest form of anemia is that due to removal of a large per- 
centage of erythrocytes from the body. This condition is fulfilled in 
acute hemorrhage. If the amount of blood lost does not exceed the 
amount necessary to maintain circulation, roughly fifty per cent of the 
total quantity, the fluid portion lost is quickly replaced from the fluids 
of the body and from material ingested. The formed elements and 
proteids are less rapidly replaced by a compensatory increase in function 
of the hematopoietic tissues so that there is a gradual return to the ori- 
ginal number and proportion. 

A blood cell may be considered as passing through a life cycle of 
infancy, adolescence, maturity, and senility before it is finally destroyed. 



The Peactice of Osteopathy • 673 

If the demand for new cells is not too great it will be met with mature 
cells. If the call is more urgent, younger and older cells will both be put 
into the conflict, while in a time of extreme stress all types of cells, from 
the "school boj^s" to the ''gray-beards", will have to be utilized to main- 
tain life. So, roughly, we can judge the severity of the anemic process 
by the reaction which the body makes to it as indicated by the character 
of the cells in service. 

The pigment, hemoglobin, is slowly regenerated even as compared 
to erythrocytes, so that the color index is usually the last finding to re- 
turn to normal after a hemorrhage. The leucocytes are usually increased 
after hemorrhage, probably as a protective mechanism, nature having 
learned by hard experience that she has less resistance to infection, when 
there is loss of a considerable quantity of blood. 

To be considered, also, is the fact that constantly blood cells are out- 
living their usefulness — some must be disposed of. The extra function 
required of these older cells gives the same results as over work upon an 
old man — hurries his time of demise so that there is a greater percentage 
than usual to be sent to the salvage shops. The regeneration of blood af- 
ter hemorrhage depends upon the severity of the loss, the nutrition, 
upon the treatment given, and indirectly the abihty of resistance devel- 
oped by the patient. 

In the chronic anemias we may have either defective development of 
erythrocytes, or defective function of them, or a relatively too great 
destruction of these same agents. 

A bank account may be depleted either by too small deposits to 
account for current expense, or by extravagant withdrawals. It is some- 
times difficult to determine on which side the fault lies. It seems to 
be nature's plan not to subject to active work an erythrocyte until after 
the nucleus has disappeared, judged by ordinary methods of staining. 
A sudden call for an increased number of erythrocytes may force the or- 
ganism to send in some with nuclei, but the circulation does not receive 
those which have not been standardized, as to shape and staining reaction, 
unless the crisis is of grave import. Evidence of increased destruction 
of these cells is shown by broken forms — shadow forms, and by an increas- 
ed excretion of the pigments derived from the breaking down of hemo- 
globin, namely bilirubin and urobilin. A great deal of information can 
l)e obtained by a study of the other formed elements of the blood. 

In general the symptomatology of all the anemias will be that of 
lessened metabohsm because of deficient oxygenation. This is accom- 
panied by imperfect nutrition and general impairment of function. 



674 The Practice of Osteopathy 

Among the usual results are muscular weakness, malaise, headache, diz- 
ziness, anorexia, and cutaneous and membranous pallor, with tendency 
to local hemorrhages. The heart is often rapid, easily disturbed in rhythm, 
may possess a hemic or functional murmui-, and gives a soft compressible 
pulse of low pressure. As a compensatory attempt the respiration may 
be rapid, but is hkely to be shallow, and dyspnea results from dispropor- 
tionately small exertions. 

There may be either troublesome constipation, or diarrhea; often 
there are alternating periods of each. In the severer forms convulsions, 
coma, delirium, stupor, localized edema of the ankles or eyelids may be 
seen. 

In general the treatment of the secondary anemias will concern 
the removal of the cause followed by measures tending to increase the de- 
creased element or elements in the blood stream. In the anemia re- 
sulting from hemorrhage the thirst which follows is the body's method of 
calling for more fluid with which to maintain pressure in the arteries 
and capillaries sufficient to develop new formed elements to take the 
place of those lost. If the loss is severe enough to give rise to shock, em- 
ergency measures are necessary of introducing into the venous stream an 
artificial fluid to make up for the fluid part of the blood lost. If the 
condition can be predicted and a suitable donor obtained, blood trans- 
fusion is of greatest advantage to the patient. More often the urgency 
of the condition will require an artificial fluid to be given in haste. Prob- 
ably the best so far devised solution is Fischer's physiological salt solu- 
tion. In the anemias due to chronic metal poisoning as from lead and 
mercury, or from systemic poisoning such as syphilis or malaria, or from 
the retention of metabolic products as in some of the diseases of the kid- 
neys or of the liver, the anemia can only be successfully treated by nor- 
malizing its primarj^ cause — as it occurs in the role of a symptom or re- 
sult, and hence is only indirectly a blood condition. 

Costogenic Anemia 

(Burns' Anemia) 

Costogenic Anemia is a result of functional disuse-atrophy of the 
hematopoietic organs, there being an insufficient supply of erythrocytes 
to meet the demands of the metaboHsm of the body. It results from in- 
suflBcient opportunity for nutrition and drainage of the red marrow of 
the ribs, and gives the clinical picture of an anemia due to too slow pro- 
duction of erythrocytes. 

Etiology. — The condition is predisposed to by any factor which 



The Practice of Osteopathy 675 

tends to limit the action and nutrition of the ribs. We are too prone 
to forget that the function of the ribs is to produce erythrocytes; it is 
really a matter of secondary importance that they make up part of the 
thoracic wall. The change from the horizontal to the upright position 
has tended to a drooping of the whole chest from gravity. The human 
animal seldom develops the free hinge rib motion as often seen in quadru- 
peds. The passage of both arterial and venous blood, is not normally 
free and copious, and as a consequence the tissue supplied functions less 
efficiently. This function of the red marrow is to produce erythrocytes. 
Any structural lesion of the dorsal vertebral column, or its costal artic- 
ulations, which interferes with the free motion of the rib thus interferes 
directly with the,efficient function of these particular ribs. The severity 
of the condition varies with the number of ribs affected and the im- 
pedance to nutrition and drainage. 

Diagnosis. — The condition may be of gradual onset, and may be 
associated or coincident with some other condition leading to a loss of 
tone or opportunity for free rib action. The systemic symptoms are 
due to a deficient oxygenation of all tissues as a result of the above disuse. 
The thorax is usually rigid — forced respiration requires unusual effort 
without proportionate thorax expansion. The type of breathing tends 
toward diaphragmatic. The quantities of tidal and supplemental air 
are both markedly decreased. The lack of tissue oxidation renders 
elimination less active, hence constipation. Gas accumulation, weak- 
ness, insomnia, with slightly increased amount of urine, and low in to- 
tal solids, is the rule. 

"The blood itself is rather characteristic. Coagulation time is in- 
creased ; specific gravity and viscidit}^ diminished ; red cell count normal 
or only slightly diminished; hemoglobin 6 to 10 grams per 100 c. c. of 
blood (Meischer); 40% to 80% (Dare). The red cells are small, pale, 
vacuolated, sometimes nucleated. The white cell count is normal, 
slightly increased or sHghtly diminished. The hyaHne cells are normal, 
or slightly relatively increased. (These, being formed in lymph nodes, 
tonsils, etc., are not affected by rib changes.) The mononuclear neurto- 
philes are relatively increased. The nuclear average of the polymor- 
phonuclear neutrophile is low. Vacuolated and atypical neutrophiles 
are often found. Basophiles, myelocytes and amphophiles. may be 
found in considerable numbers. Nuclei in all granular forms present 
evidences of immaturity or degeneration — they may be swollen, vacuol- 
ated, extruded, ragged, or with variable staining reaction " (Clinical 
Osteopath v). 



676 The Practice of Osteopathy 

Treatment. — The treatment is to obtain a normal function in the 
inactive tissues. This is done by getting better rib hygiene. What- 
ever is interfering with rib function and metabohsm is to be removed. 
Breathing exercises are given not only to "ventilate the thorax, but 
to exercise its walls". Carefully selected horizontal bar work is often 
of great value. The diet should be of such nature as to supply 
material for manufacture of erj^throcytes and for loading them with hemo- 
globin as w^ell. Hence the foods with high chloi'ophyl or hemoglobin 
content should be emphasized. 

Prognosis. — This depends on patient's desire for improvement of 
his condition. He can be improved by correction of whatever lesions 
there may be interfering with his freedom of thoracic motion. He can be 
benefited by manipulations which adjust the ril)s, but his cooperation is 
essential. Lack of cooperation on the part of the patient, which would 
tend to increase the mobihty and metabolism of the ribs, renders him more 
liable to any of the interciirrent pulmonary infections, as a result of his 
deficient thoracic ventilation. 

Encourage free thoracic respiration especially when in school, or 
when under conditions which ordinarily would tend to slovenly habits 
of breathing. 

Chlorosis 

(Green Sickness) 

An anemia characterized by great reduction in the amount of hemo- 
globin. It most frequently occurs in adolescent girls. It seems to be 
associated with neurotic manifestations and menstrual irregularities. 

Etiology. — Its cause is not well understood. Poor hygienic con- 
ditions may be a factor, but it is a condition found in all stations of life. 
The age and sex have led to investigation as to probability of lack of 
an ovarian internal secretion. The reports of workers are contradictory. 
The name of the condition is derived from the color of the skin, which 
usually ranges from a pale greenish tint to a slight pallor. Occassionally 
there is locahzed vasodilation of the cheeks giving brilliant color. Con- 
stipation accompanied by copremia seems to be either a causative factor 
or result. In many cases it appears to act in the dual role. Fixation of 
the middle and lower ribs accompanied by osteopathic lesions from the 
mid to the lower dorsal spine seem to be constant findings. The costal 
fixation leads to lessened respiratory excursion and resulting diminished 
oxygenation. 



The Practice of Osteopathy 677 

Diagnosis. — Chlorosis may be suspected from the color of the skin, 
perverted appetite, wandering nem-algias, heart palpitation, edematous 
infiltration, and shallow type respiration, but the diagnosis is not to be 
made without the aid of the blood count. The striking part of the blood 
picture is the great reduction in amount of hemoglobin carried by each 
erythrocyte. There is usually some reduction in the erythrocyte per- 
centage but not in proportion to the decrease in color index. 

There are usually many pessary-shaped and shadow erythrocytes. 
These are of all sizes, but seldom is the condition of such gravity as to 
cause more than an occasional nucleated red cell, and when found are most 
likely to be normoblasts. The staining reaction is of wide hmits. Cells 
of all degrees of relative alkalinity are found and often there is a wide 
v^ariation of staining reaction in the same cell. The number of erythro- 
cytes is usually shghtly decreased but not in the proportion that the hemo- 
globin percentage is, so that the color index is therefore strikingly low. 
Probably, the average color index for a typical case of chlorosis is 50, 
with an erythrocyte count of 4,000,000 and a hemoglobin of 40 per cent 
(Dare.) This drop in color index in chlorosis is far out of proportion to 
the chnical symptoms which would be expected from a similar reduction 
resulting from the ordinary causes of secondary anemia. The blood 
plasma is increased and the specific gravity is lowered, sometimes reduced 
from 1.055 to about 1.030. 

Treatment. — The treatment of any malady in which the etiology 
maj'- be apparently of widely different natures will naturally rationally 
vary with the apparent cause. If there is copremia, which seems to be 
a definite causative factor, this should be at once corrected. These 
patients form the cathartic habit readily, so phj^sical and dietary methods 
of returning the digestive motility to normal should logically be given 
first trial. If it is a matter of lessened metabolism as a result of insuffi- 
cient exercise, or blood oxygenation, out-door gymnastics and breathing 
exercises may incite the. stimulus to normal erythrocyte hemoglobiniza- 
tion. The diet should be of such nature as to furnish material both for 
erythrocyte formation and iron in form for ready absorption by them. 
The organic iron compounds of animal hemoglobin and vegetable chlor- 
ophyl are our most common and cheapest as well as most effective sources. 

The medical treatment of chlorosis is based on the empiric use of 
inorganic iron. "The exact method in which iron exerts a favorable 
influence upon chlorosis still remains unsettled. It is difficult to under- 
stand why iron salts in the food which are sufficient for all ordinary 
needs, are insufficient in chlorosis. It seems most probable that iron cures 



678 The Practice of Osteopathy 

chlorosis by acting as a stimulant to the blood forming organs" (Bei- 
feld, The Basis of Symptoms.) 

Clinically, osteopaths are daily obtaining rationally the necessary 
stimulus to the blood forming organs by removing all impedance from 
these organs caused by vertebral and costal lesions and by obtaining 
better digestive and respiratory hygiene. 

Prognosis. — Recovery is to be expected and its rate will depend 
upon the thoroughness of the osteopathic work and the patient's ability 
to respond to the stimulus. The blood may show chlorotic relapses 
with concomitant symptoms if in later life secondary anemia develops 
from hemorrhage, hookworm infection, or other causes. 

Pernicious Anemia 

This anemia is of obscure etiology, characterized by progressive de- 
structive hemol3^sis of the erythrocj'tes, usuall}^ with fatal termination. 
The cells retain their hemoglobin carrying abilit}^ so that while the hemo- 
globin is decreased in percentage, the proportionately greater decrease in 
the number of erythrocj'tes leads to a marked increase in the color index. 
The destructive influence upon the red cells may be sufficient to allow on- 
\y a small percentage of the erythrocytes to appear normal and show the 
greater number to be deformed, or in various stages of degeneration. 
Cells which in times of health would have been sent to the "salvage sta- 
tion" are retained to carry an over-load for them of hemoglobin to the 
needy tissues. Immature nucleated cells of all types are drawn into 
the battle long before they can be efficient carriers to help supply oxygen 
to the tissues. Seldom will a secondary anemia be severe enough to 
produce megaloblasts in the blood stream yet they are a rather con- 
stant finding in pernicious anemia. With these cells of irregular carry- 
ing capacity and development, anisocytosis and polychromatophilia are 
expected findings. 

Symptoms. — The condition must be regarded as a sjinptom com- 
plex or a result of pathologic process or processes. A type of anemia 
very similar in symptoms and blood findings to the pernicious anemia 
is produced by the toxins of advanced malignancy, and by at least two 
forms of intestinal parasites, the ankylostoma duodenale and the bothri- 
ocephalus latus. In the true pernicious anemia we have similar results 
but are not able to locate the primary pathology. There are present syn- 
chronously, enormously increased destruction of erjiihrocytes and enor- 
mously increased production of them but we are unable to determine 
which is primarih' at fault. The belief that the cells are more fragile 



The Practice of Osteopathy 679 

and too easily broken up has led to the removal of the erythrocyte de- 
stroying spleen in the hope that destruction would be delayed until re- 
generation of even imperfect cells would balance the need. Occasionally, 
the algebraic sum of regeneration and destruction may be apparently 
balanced and not tell the tremendous amount of pathology both produc- 
tive and destructive, that the body is going through. 

The first sjanptoms are of easily produced fatigue of all the body, 
brain, muscles, diminished digestive secretion, and dyspnea. As a 
result of poor tissue oxygenation, fatty degeneration takes place in the 
more active organs as the heart, kidneys and liver. There may be ex- 
tensive degeneration of varying areas of the central nervous system. 
Some of these areas are due to hemorrhages from the general tendency 
to breaking down of vessel walls. Often these areas of destruction affect 
the posterior horns of the spinal cord, and, occasionally, a blood count 
differentiates between similar symptoms of pernicious anemia and tabes 
dorsaHs. There is seldom any emaciation; usually the patient appears 
"puffy" with a "pasty" color. There is variable sub-cutaneous edema. 
The symptoms being of such wide distribution and character, the patient 
is usually treated for all sorts of supposed conditions until some one 
makes a blood count at a time when there is enough disturbance of equi- 
librium to give the findings of pernicious anemia. 

Treatment. — The treatment of the form due to intestinal parasites 
gives striking results on removal of the causative organisms. Some 
advise treating all cases having these blood findings on the assumption 
that the presence of these parasites is responsible for the condition. 
The treatment of the idiopathic form resolves itself into building up 
the ability of the body to resist disease and the removing of all possible 
agents for depressing the vitahty of the body. Rest in bed coupled 
with the digestible and assimilable hmit of nutrition often gives tempor- 
ary improvement. Removal of questionable teeth also often aids for a 
time. Correction of troublesome osteopathic lesions is often accompanied 
by the same result. The symptomatic osteopathic treatment always 
makes the patient more comfortable, often gives temporary improvement, 
and, occasionally, has given a return to normal that has persisted for sev- 
eral years. 

Prognosis. — It is nearly always possible to obtain transient im- 
provement, but the pernicious anemia patient is usually dead within 
two 3^oars from the time the diagnosis is well established. 



680 The Practice of Osteopathy 

The Leucemias 

As a result of any inflammatory process, there is a physiological 
reaction or stimulus leading to an increase in the number of neutrophilic 
leucocytes found in the peripheral circulation. As long as this increase 
does not crowd out other cells, red and white, sufficiently to interfere 
with their abiUty to function there is nothing but gain to the body of the 
character of more efficient bacterial destruction. After the need for 
these cells has passed, their number is decreased by destruction and the 
lessening of their production, until an equiHbrium is reached which will 
be maintained. 

This same process of making and destrojdng is constantly- going 
on for all of the different classes of cells found in the blood stream. Over- 
production of any type will lead to actual increase of that sort of cell 
in circulation, and, if unaccompanied by over-production of other types, 
will lead to a relative decrease of the other elements. 

It is very difficult for the body to furnish normal cells very much 
in excess, relatively, of the normal number, so that when the stimulus 
leading to immense over-production is at work immature cells in great 
numbers are apt to be thrown into the blood stream. As an example, 
the case of leucocytosis which has a white count of 60,000 is extreme and 
the patient nearing death, yet it may not show manj^, if any, abnormal 
types of cells. A case of myelogenous leucemia with a white count of 
60,000 would not be proportionately sick, and would be a mild case — 
yet the greater part of his white blood content would be made up of cells 
not found in normal blood. The leucocytosis patient is suffering more 
from the cause of his increase in number of cells, while usually the leuce- 
mia patient suffers because of the increase of cells. In one, the cause is 
usually extrinsic, and, in the other, it is intrinsic as far as the blood is 
concerned. 

In general, then, the symptoms of a leucemia parallel in intensity 
the increase in cells. It takes energy to make these cells — other tissues 
are made to suffer from lack of this energy. Erj^throcytes and white 
cells cannot occupy the same space at the same time. The increase in 
white therefore crowds the red cells out of function. Disease in relative 
and absolute content of erythrocytes decreases the oxygen carrying ca- 
pacity of the blood stream. Hence, metabolism of the whole body suf- 
fers. Often, then, the whole apparent symptomatology of a severe leu- 
cemia is that of a secondary anemia. 

The primary pathology is of hyperplasia of the particular genetic 
tissue of the type of cells which are in excess, and is proportionate in 
amount to the excess developed. 



The Peactice of Osteopathy 681 

Splenomedullary Leucemia 

(Myeloid Leucemia; Myelemia) 

M3^elemia is a disease characterized by an enormous increase in the 
white cell content with proportionate changes in the spleen, liver, and 
the blood marrow. 

Etiology. — It is a disease occuring at all ages, but the majority of 
cases are recognized in adult males. 

Heredity, trauma to the spleen, malaria, syphiUs, and rapid repeti- 
tion of pregnancies seem to be at least exciting factors. A few cases 
have been reported in which tenth, eleventh, and twelfth rib lesions were 
definite etiologic factors by pressure. 

DiagnosiSo — The patient goes through a period of vague, indefinite, 
and wandering s\Tiiptoms. General malaise, weakness often accompan- 
ied by dyspnea, and emaciation similar in many ways to incipient pul- 
monary tuberculosis, except that the sKght temperature changes are not 
typical. At the same time there may be digestive discomfort of var- 
ious kinds without tj^pical pathology. Of these early symptoms the 
most persistent is the dyspnea which is a structural result of the in- 
crease in size of the spleen . As a direct pressure result of this hyperplasia, 
there may develop dropsical infiltration of the lower extremities and as- 
citic accumulation in the abdominal cavity. 

With the changes in the blood itself, the blood vessel walls break 
down more easily, and subcutaneous hemorrhages, epistaxis and hema- 
teraesis are common. 

In an attempt to destroy the excessive amount of white cells, the 
liver msiy become enlarged. But this occurs later and of much less de- 
gree than the enormous increase in size of spleen. There may be areas 
of hemorrhage with resulting softening in the spinal cord. The most 
likely areas to suffer are the posterior and lateral horns, with resulting 
paraplegia, spastic or ataxic. 

Usually, the course is slow, and the condition is truly chronic. But, 
occasionally, the rapid increase and succession of symptoms, with con- 
comitant blood changes, change the diagnosis to acute myelogenous 
leukemia. 

The total cell count, red plus white, is diminished, for while there is 
enormous relative increase of the white cells a gi'cater actual decrease 
takes place in the reds. This decrease in reds is partially relative from 
crowding out of erythrocytes by leucocytes, but there is also actual de- 



682 The Practice of Osteopathy 

crease in their formation, so that there is an actual anemia present as well 
as a leukemia. 

In some respects the red cells behave as in chlorosis, each carrying 
a diminished percentage of hemoglobin, resulting in a low color index. 
Atypical staining reactions and morphology, together with many fractur- 
ed forms, are the rule. Normoblasts are common throughout the course 
of the disease, but megaloblasts seldom appear until near fatal termina- 
tion. 

The changes in the white ceUs are enormous, both as to numbers and 
character of cells found. The total white count often exceeds 350,000. 
This, with the accompanying reduction in number of erythrocytes, leads 
to a reduction of the ratio between reds and whites to as low as 1 to 5 or 
3, or occasionally 1 to 1. There is an actual increase in number of all the 
white cells with the possible exception of the lymphocytes. In the 
actual increase of polymorphonuclear neutrophiles and eosinophiles is 
rendered a sharp relative decrease by the enormous production of myelo- 
cytes. Basophiles are usually both relatively and absolutely increased. 
In a white count of 350,000 it is not unusual to have present 325,000 
myelocytes, with 25,000 as the actual number of ordinary leucocytes. 
There is, therefore, a mild leucocytosis coupled with a violent leuke- 
mia. These two are coml^ined with an anemia that varies with the 
course of the disease. 

Treatment. — The treatment is largely hygienic, including thorough 
osteopathic attention to the lower dorsal and costal area. Symptomatic 
treatment is often followed by temporary improvement both cHnically 
and in the blood picture, but complete recovery seldom takes place. 
Occasionally, roentgen therapy has given a "cure" lasting several years. 

Prognosis is not good. These patients are frequently carried 
away quickly bj' some oftentimes slight intercurrent infection. Even 
if carefully guarded from such, the course of the process usually leads to 
death from exhaustion in two or three j'^ears. 

Lymphatic Leucemia 

Clinically, this is a parallel condition to myelogenous leucemia, 
except that the hj^perplasia of cells occurs in lymphoid tissue, and leads 
to an enormous over-production of honphocytes rather than myelocytes. 
It is more readily divided into acute and chronic forms than myelogen- 
ous leucemia from differences in s3^nptomatology. 

In the acute form, adolescents are usually affected, the condition 
beginning with tumefaction of the lymph glands, first noted in the cervical 



The Practice of Osteopathy 683 

region, but usually a general involvement. Dyspnea results from pres- 
sure upon treachea and bronchi by the enlarged glands of the medias- 
tinum. There is pyrexia of 103 to 105 degrees, intermittent in character. 
The pressure upon nerve trunks and plexuses in the thorax leads to 
variable anginas distributed not only in regions actually imposed upon 
but over all sorts of possible reflex paths. The blood vessels of the skin 
are easily broken down so that slight injuries result in great suggillation. 
The patient rapidly develops anemia, and later goes into a syndrome 
similar to the cachexia of malignancy. In fact, the rapid termination 
and cHnical course of acute lymphatic leukemia is parallel to the action 
of mahgnancy. Probably the condition will eventually be properly clas- 
sified as a neoplasm of the blood itself. 

The chronic form occurs in later life, and, instead of being an ab- 
rupt rapid process, is slow, progressive and painless. It has the lymph 
gland hyperplasia, but the enlargement is so gradual that compensation 
's estabhshed to a remarkable degree. It is usually a generahzed process, 
first noted in the cervical and axillary glands because of their accessi- 
bility. Usually both the spleen and liver are enlarged, but this also is 
a slow and later development. 

There may be exacerbations of temperature, but they are not con- 
stant or usually severe. Hemorrhages into the skin are not common, 
but pruritus may be very troublesome. 

The patient comes to a physician because of sjTnptoms resulting from 
his secondary anemia, dyspnea, dyspepsia, and palpitation. 

The diagnosis cannot be made without the aid of a blood study. 
The blood picture shows a severe anemia with both the number of erythro- 
cytes and the hemoglobin percentage very much lowered. Of the two 
findings, the hemoglobin percentage is relatively more decreased, so that 
the color index is markedly lowered. 

In the acute form nucleated reds are common. Just before death 
these may show various forms and sizes as well as the normoblasts. In 
the chronic form normoblasts do not appear except as the case grows 
decidedly worse. As compared to myelogenous leucemia the anemia 
of lymphatic leukemia is of greater severity. 

In the leucocyte count there is great increase in numbers, the greater 
part being composed of the lymphocytes. The lymphocytes may be 
cither of the large or small variety, and occasionally are found in about 
equal proportions. In contra-distinction to the myelogenous type, the 
increased type of cells are of the mononuclear nongranular types. It is 
not very unusual to find a well advanced case of lymphatic leucemia 



684 The Practice of Osteopathy 

without abnormal cells in the blood count, the expression of pathology 
being in the shape of disturbance in number and proportion of cells rather 
than in development of abnormal types. The actual number of leuco- 
cytes does not go as high in proportion to the gravity of the condition in 
Ij^mphatic leukemia as it does in the myelogenous. In other words, a pa- 
tient with lymphoid leucemia showing a count of 90,000 leucocytes with 
90% of these lymphocytes is a much sicker man than the myelogenous 
case showdng a 350,000 leucocj'te count. 

Usually there is an actual as well as relative decrease of all the granu- 
lar types of leucocytes with the polymorphonuclear neutrophiles especial- 
ly decreased. 

The treatment is sj'stemic and sjaiiptomatic. Recovery is not to 
be expected, but these unfortunates can be made relatively comfortable 
and given occasional respite by judicious osteopathic care. 

Hodgkin's Disease 

(Lymphadenoma; pseudo -leucemia) 

In a general way, the several conditions which are cHnicall}^ leucemia, 
yet do not possess leukemic blood, can be classified as pseudo-leukemias. 
We do not definitely know the cause of leucemia as yet and can but ht- 
tle more than speculate on the various etiologic factors of the pseudo- 
leucemias. 

Syphihs, malaria, tuberculosis, and malignancy are all considered 
as factors, and probably certain cases can be definitely associated with 
these conditions. 

All of this group of pseudo-leucemias are characterized by early 
swelHng of cervical hTuph glands, followed b}^ general gland enlarge- 
ment, and b}^ great destruction of the erythrocytes. There may be 
metastatic-Hke growths of lymphoid tissue in other organs. The en- 
largement of cervical glands usually begins on one side near the angle of 
the jaw, and most commonly in young male adults. These glands pro- 
gressively increase in size, first are soft, then later become hard through 
fibrous proliferation. Each gland tends to increase in size by itself, not 
to coalesce with its neighbors, so that each separate gland can be pal- 
pated. This is more readil.y done as there is Httle tendenc}'- to fibrous 
adhesion formation to the overlying skin. These glands are painless 
throughout the course of the disease, and tend neither to caseate nor to 
suppurate. 

The excised glands show a combined hyperplasia and connective tis- 
sue proliferation. In the soft stage of the tumefaction, the lymphoid 



The Peactice of Osteopathy 685 

hyperplasia is in preponderance, while, at the stage of hardening, the 
fibrous tissue derived from the trabeculae and capsule of the gland is in 
prominence. There is increase in the size of the spleen, and occasionally 
of the liver, but these are never as marked as those resulting from leucemia. 

The symptoms are, first, those due to the glandular enlargement in 
the order of: dyspnea, hydrothorax, dysphagia, ascites, swelling of the 
extremities, and jaundice. 

The destruction of red cells gives a resulting anemia which goes 
with and exaggerates the pressure symptoms. 

A process of this kind to induce such grave changes over as well 
protected organs as make up the Ij^mph system, must be virulent enough 
to set up other symptoms, to be associated with those due to pressure or 
to anemia. These are usually emaciation (giving greater prominence to 
glandular tumefaction), cachexia, and the implantation of masses of 
lymphatic tissue in organs where normally only traces of this tissue ex- 
ist. 

Fever is dependent upon the disturbed thermic metaboHsm and may 
be practically absent or subject to wide variations. 

The erythrocyte count shows a progressive decrease with a greater 
proportion of broken down cells and abnormal types as the condition 
advances. The actual count is usually between 2,000,000 and 3,500,000 
per cubic milHmeter. The hemoglobin usually reduces in proportion to 
the erythrocytes, so that there is Uttle change in color index. 

The leucocytes are not markedly changed in number (seldom over 
10,000), and this is often the diagnostic finding between leukemia and 
the pseudo-leukemias. Hodgkin's disease usually has a high percentage 
of lymphocytes, so that there is an actual as well as relative decrease of 
the granular leucocytes. 

The treatment is unsatisfactory, and is in the main symptomatic. 
Roentgen therapy has given temporary improvement, in some cases 
lasting several years. In general the prognosis is hopeless, the end oc- 
curing within four years of the time the condition is recognized. 



686 The Practice of Osteopathy 

DISEASES OF THE THYROID GLAND 

Congestion 

Physiological congestions of the thyroid gland are not uncommon 
during puberty, painful menstruations, pregnancy, and the menopause. 
The premenstrual congestion may persist after the menstrual function 
has been established, but this is comparatively rare. When the en- 
largement remains there is more or less hypertrophy, and it should receive 
appropriate treatment. Upper dorsal and cervical lesions are common. 
The congestion during pregnancy occurs in the majority of cases and 
seems to be a physiological process, wherein there is more or less hyper- 
trophy and hyperplasia, which probably counteracts the waste products 
especially caused bj^ this state, \>y due to the inactivity of the ovary. 
During delivery the gland may rapidly enlarge and remain so for an in- 
definite time. It seems probable that the straining due to labor may 
cause lesions of the upper dorsal and neck that will derange the function 
of the organ. When the enlargement occurs during the menopause 
special care should be taken that the goiter is not malignant. 

Other possible causes of congestion are overfatigue, particularly 
when associated with heavy lifting; tight clothing about the neck; over- 
use of the voice; and in a few cases it may be discovered in boys at puberty. 

The symptoms are congestion, the gland being very vascular, either 
soft or tense, somewhat painful owing to the tension of the capsule, and 
in persistent cases there may be hypertrophy and hyperplasia. The treat- 
ment is the same as given under simple goiter. 

Inflammation of the Thyroid 

Inflammation of the thyroid is not of frequent occurrence. In the 
several cases that the authors have seen there was some previous en- 
largement of the organ, which probably caused a lowered resistance 
of the local tissues. There is almost invariably some infection elsewhere 
in the body. The exciting causes are usually streptococcus, staphylococ- 
cus, or bacillus coli. The inflammation may follow pneumonia, tonsilhtis, 
rheumatism, typhoid, puerpal infections, enteritis, diphtheria, influenza, 
mumps, etc. Trauma, carrying weights on the head, and cold, may be 
etiological factors. 

Commonly, one lobe is involved, though the entire gland may be 
affected. There is swelling, the capsule is distended and painful, and 
small hemorrhages occur which in the case of suppuration form the site of 



The Practice of Osteopathy 687 

the abscess. The sweUing involves the parenchyma and interstitial 
tissue. 

The onset is usually sudden with chills, fever, and pain over the 
glands. The patient keeps the head flexed to release the muscular ten- 
sion, swallowing is painful, and there is a sense of constriction. A rapid 
heart may be a prominent symptom. Much depends at this period on the 
treaiment given. If the drainage can be freed, by lowering the first 
ribs and raising the clavicles with attention to the dorsal and cervical 
innervation, prompt subsidence of the condition commonly takes place. 
This should be carefully accomplished in order not to bruise the parts. 

Diagnosis is not difficult as a rule. The symptoms and historj^ of 
infection will generally suffice. Hemorrhage may occur in a goiter and 
somewhat simulate inflammation. A possibility of malignancy is to 
be considered. 

If the condition does not yield to treatment, surgical interference 
may be necessary. 

Tuberculosis and syphilis of the thyroid are rare conditions. 
Woody thyroiditis may be mistaken for mahgnancy. The gland is 
very fibrous, and when cut has a dry surface. The connective tissue is 
hardened and crowds upon the parenchyma. This condition is usually 
found in young men. It develops rapidly, with more or less pain and dys- 
pnea. Adenocarcinoma, carcinoma, and sarcoma are rare diseases^ 
still one should be on his guard as to their possibihty. They are most 
apt to occur after forty. A rapid enlargement should be regarded with 
suspicion. 

Simple Goiter 

We employ the term simple goiter to designate chronic enlarge- 
ment of the thyroid gland not due to inflammation, exophthalmic goiter, 
or mahgnancy, although the latter conditions are frequently associated 
with or follow the former. There is usually an enlargement of the gland 
in cretinism, and occasionally in myxedema, but the functional grade of 
the gland is far different from that in other diseases of the thyroid. 

The disease is very prevalent in certain regions of Europe and Asia, 
although in the United States it is not so common, except in the environs 
of the Great Lakes, the District of Columbia, and the Northwest states. 
The second decade of fife, probably owing to adolescent changes, es- 
pecially in girls, develop the greater number of goiters. It is infrequent- 
ly congenital, and occasionally a case will develop as early as four or five 
years of age. 

1. Ewing, Neoplastic Diseases; Grotti, Thyroid and Thymus. 



688 The Ppuctice of Osteopathy 

Etiology. — Distiirljed innervation of the gland unquestionably 
seems to be the predisposing cause of the deranged secretion and vascular 
changes, which if continued finally lead to hypertrophy and hyperplasia 
of the tissues. These lesions are found from the fifth dorsal to the occi- 
put and to the corresponding ribs. They probably involve secretory 
fibers of the sympathetic that emerge from the upper dorsals, first to fifth 
inclusive, maximum effect second, third and fourth. "Evidence is pre- 
sented that the impulses pass to outlying neurones whose cell bodies are 
located close below the superior cervical ganghon and also in the infer- 
ior cervical ganglion. "\ In both these ganglia impulses to the thyroid 
pass from preganglionic fibers to the outlying neurones. This also in- 
cludes the area of vasomotor^ innervation of the head and neck. 

In a number of cases cervical lesions alone will disturb the thyroid 
innervation, especially from the second to fourth segments. These may 
involve the superior cervical sympathetic, owing to its relationship to 
the rectus capitis anticus major muscle. Then there are afferent asso- 
ciation fibers that pass down through the lateral horns and whose con- 
necting fibers emerge via the upper dorsal. 

The lymphatic drainage of the thyroid should not be neglected. 
Lesions of the upper ribs and clavicles are very prone to impede its cir- 
culation, and thus predispose to secondary infections. 

Infection from septic foci are important secondary factors. This 
is particularly true of focal infections of the upper respiratory tract 
and buccal cavity, although infections and toxins from various regions 
may be exciting factors. Toxemia due to intestinal stasis is not rarely 
an important consideration. 

McCarrison insists that infection from certain waters is the cause 
of goitei-. He finds that boiling the water renders it harmless. 

Pathologically, the first effect upon the gland is to lessen its iodine 
content. The circulation is increased, with hyperplasia of the epithelial 
tissue, and a lessened amount of colloid material. If the condition con- 
tinues, the alveoli will again become distended with the colloid material 
so that the epithelial tissue cells are almost flattened. This represents 
the so-termed colloid goiter. The gland, commonly the whole organ, 
though one side may be involved, is fairly uniform in size. In rare in- 
stances, the gland may surround the trachea — the so-termed circular 
goiter. Hemorrhages may occur, and there may be various alterations 

1. Cannon and Cattell, The Secretory ennervation of the ThsToid Gland, Am. 
Journal of Physiology, July, 1916. 

2. Gaskell, Involuntary Nervous System. 



The Practice of Osteopathy . 689 

and degenerations. When the vessels are much dilated, it is often called 
a vascular goiter, though the colloid changes are present. 

The nodular goiter is another form characterized by new forma- 
tion of gland tissue that is not diffuse but circumscribed. These cases 
are apt to follow persistent involvement of the gland at puberty. The 
two forms may occur together, and there may be various combinations 
and changes. In the nodular goiter there is comparatively Kttle colloid. 
There are many blood-vessels, and small hemorrhages are frequent. 
This latter point should be remembered by those who treat over the gland, 
which at best is a doubtful procedure. Various changes may take place, 
as local points of necrosis, cystic formation, and calcification, are not 
uncommon. 

Symptoms. — The essential feature in goiter is distension of the 
alveoh and formation of new ones, associated with dilated vessels, and 
usually degeneration of the colloid. Often the function of the gland 
is not noticeably disturbed. Usually, it is for the pressure symptoms or 
the unsightliness, due to the distension, that the patient seeks relief. 
Pressure upon the windpipe, gullet, or blood-vessels is not rare, and may 
cause more or less difficulty in breathing or swallowing. Coughing and 
huskiness may be troublesome. The recurrent nerves and vagus raa.j 
be compressed. Disturbance of the heart, such as palpitation, tachy- 
cardia, and hypertrophy may be caused by the effect of pressure upon 
the blood-vessels, or to changes in the secretory function of the gland. 

Treatment. — Adjustment of the upper dorsal and cervical lesions 
will be followed by recovery in the majority of cases. Dr. Still empha- 
sized the point that the vertebral ends of the first ribs are frequently 
displaced upward and outward. This lesion is often found in cases fol- 
lowing confinement. The effect of the change here is probably to the 
stellate ganghon, or to the lymphatic drainage of the gland. Treatment 
over the gland should be cautiously given, if at all. Definite correction of 
the lesioned vertebrae and ribs will be sufficient, but muscular manip- 
ulation and halfway measures are practically useless. 

Lesions of the lower spine may be the primary source of a compensa- 
tory lesion of the upper dorsal, or they may derange the pelvic organs, 
or be the predisposing factor of intestinal stasis. Attention to possible 
focal infections, and thorough ehmination, are to be considered. In 
goitrous regions boiling the water is of value. In obstinate cases the 
X-ray may be of service, and as a final resort surgery may be employed. 

''Marine observed that the amount of iodine is inversely proportion- 
al to the degree of hyperplasia of the gland, and when the hyperplastic 
coiidil ion ])ecomcs fully developed, scaix-ely a trace of iodine is contained 



690 The Practice of Osteopathy 

in the gland. Later, when the hyperplasia gives place to colloid goiter, 
the iodine increases again, both absolutely and relatively. Moreover, 
it has been found that if iodine be administered to an animal suffering 
from hyperplasia, the hyperplastic condition very quickly disappears 
and the animal becomes normal. "\ His viewpoint of the hyperplasia 
is that an effort is being made to compensate for an "insufficiency due to 
inabihty to absorb or assimilate sufficient iodine", and thus the effect 
of the administered iodine is to normalize the gland by stimulation. 

No one can question that this may be effective under certain condi- 
tions, particularly where there is deficient iodide in the water, but it 
is an essential element of the body. But it does not necessarily follow 
that because in thyroid disturbance the relationship between thyroid 
functioning and the substance containing iodine is upset that recovery 
depends upon furnishing more iodine to the body economy. It may be 
somewhat parallel to giving iron in anemia, when often the real difficulty 
is one of assimilation, and not insufficient iron in the alimentary canal. 
Moreover, case after case of goiter has recovered through osteopathic 
measures following a most thorough trial of the iodine treatment. It is 
very obvious that the cause of the goiter rested elsewhere. Dogs are 
susceptible to thyroid enlargement. Lesioning of the cervical region has 
resulted in goiter formation, and recovery has followed adjustment of 
the lesion. And dogs having goiter without experimental lesions have 
frequently been normalized by adjusting an abnormal cervical spine. 

Exophthalmic Goiter 

In exophthalmic goiter there is an excess of the thyroid secretion 
or thyroid autacoid which passes into the circulation, due to hypertrophy 
or hyperplasia of the secreting cells. The disease is characterized clini- 
ally by nervousness and irritability, rapid pulse, flushed and moist skin, 
tremor, and increased nitrogenous metabolism. A goiter is usually pres- 
ent, but not always noticeable. There is apt to be protrusion of the eyes, 
especially after the disorder is established, though it may never appear. 
A disturbed coordination of the muscles of the eyelid, eyeball, and orbit 
are frequent characteristic symptoms. 

Etiology. — The essential factor in the cause of this disease is prob- 
ably osteopathic lesions that irritate the secretory fibers of the thjToid 
tissue. These lesions are almost invariably found in the upper dorsal, 
first to fifth, and most often locafized at the second-third or third-fourth 
segments. They are definite interosseous changes, combined rotation 
and lateral flexion, and are generally very sensitive upon palpation. The 
1. Macleod, Physiology and Biochemistry'in Modern Medicine. 



The Practice of Osteopathy 691 

constant stimulus thus produced passes through the sj^mpathetic fibers 
to the cervical ganglia, and thence to thyroid secreting tissue, which 
through vascular changes and hypertrophy and hyperplasia increases the 
output of the thyroid hormone. 

The sensitiveness of the lesions is probably of more than passing in- 
terest. For this actual tenderness is not to be confused with a neuras- 
thenic state, which may be associated with the disease, or even be a source 
of confusion in the diagnosis. The lesion is of such a distinct character 
that there is considerable local irritation and congestion. This constant 
stimulus is a cause of the increased number of impulses carried to the sym- 
pathetic, and results in not only an excess of thyroid secretion and the 
concomitant hypertrophic changes, but also in the rapid removal of the 
colloid into the circulating blood. This seems to be a very important 
link in the pathologic chain. 

Other underlying lesions may be present, as outlined under simple 
goiter, and do not require repetition here. 

The mechanism of the thyroid gland may be further upset or derang- 
ed by various exciting causes, such as focal infections, toxic states, in- 
testinal stasis, and occasionally an enlarged thymus is an important 
factor. An inherited neuropathic tendency, excessive strain, worry, and 
mental shocks may have more or less influence in either predisposing or 
exciting the disorder. 

The particular points for the practitioner to remember are that ex- 
ophthalmic goiter is due to a toxic state, of which there are many grada- 
tions, from the excessive secretion of the thyroid gland; that the normal 
resistance of the gland is lowered through definite lesions of its innervation 
or circulatory channels, or occasionally of lesions of the other organs of 
internal secretion which are closely associated ; that infections and toxins 
are often important considerations; and that direct manipulation of the 
organ may increase the disorder. 

Pathology. — The enlargement of the thyroid gland is commonly 
an early symptom, occuring before the nervous, cardiac and exophthal- 
mic manifestations. There are instances where it follows a simple goiter, 
although Graves' disease does not seem to be any more prevalent in re- 
gions where simple goiter is endemic than elsewhere. In these particular 
instances intestinal toxemia is often present. There are cases where the 
gland is very slightly enlarged, containing only small areas of hyperplasia. 
There is usually very little colloid, though there may be marked excep- 
tions. It should be emphasized that there are various degrees of changes 
found in the gland though fimdamentally of the same order. The l)lood 
supply is estensive, and the veins expecially are fragile. The alveoli 



692 The Practice of Osteopathy 

are distorted, due to the incresee of epithelial cells. Lymphoid nodules 
are frequently noted through the glandular tissue. 

Research work of unusual interest to the osteopathic physician 
pertaining to the etiology and pathology of exophthalmic goiter has 
been carried out at the Mayo Clinic. An examination of cervical sympa- 
thetic ganglia removed at operation from such cases and certain animal 
experimentation has given definite results. The following is a summary 
of their principal findings: 

"Degree of hyperpigmentation, granular degeneration, and reduc- 
tion in the number of cells was in direct ratio to the continuance of symp- 
toms of hyperthyroidism. The increased amount of perivascular con- 
nective tissue generally throughout the gland was similarly in direct 
ratio to the time during which symptoms of hyperthyroidism had con- 
tinued. 

"Increase of connective tissue in the ganglia from the chronic cases 
may be interpreted as due to the irritation from inflammation, or as merely 
a replacement following the destruction of the ganglionic nerve cells. 

"Ganglia were intimately connected by firm adhesions to the sur- 
rounding tissue. 

"There were changes in the outer and middle coats of vessels, and 
in the nerve fibers. There was an increase of connective tissue through- 
out the gangHon. 

"It appears that definite histologic changes do occur as (a) hyper- 
chromatization, (b) hyperpigmentation, (c) chromatolysis, and (d) 
atrophy, or (e) granular degeneration of the nerve cells. All of these 
are but successive steps in degeneration which, if uninterrupted, proceed 
to complete destruction of the ganghon cells affected. Not all of the gan- 
glion cells in any of the ganglia examined were so completely destroyed 
as to render improbable their return to normal under favorable condi- 
tions. There is some evidence that in ganglia from cases cHnically 
improved some of the cells have partially or wholly recovered. "^ They 
are inchned to the view that local infection in the cervical sympathetic 
gangha plays an important part in the etiology. 

The above pathologic changes of nerve fibers and ganglia support 
in many ways the findings noted at the A. T. Still Research Institute, 
not alone in the cervical region but in other regions of the body, that is, 
they are changes common to interosseous lesion pathology of various 
areas of the spine, and thus are predisposing factors that establish lowered 
resistance of tissue and derangement of function. 

1 . Collected Papers of the Mayo Clinic, 1916, '17, '18. 



The Practice of Osteopathy 693 

An important feature of the pathology is hyperplasia of the thymus. 
Simmonds finds it enlarged in three out of four cases. MacCallum^ has 
found it enlarged in all autopsies that he has seen. The lymphoid struc- 
tures of the spleen, hver, kidneys, intestines, and bone marrow is in- 
creased, while the lymphatic glands of various regions of the body may 
be enlarged, especially the cervical, bronchial, and axillary. This is 
probably due to a toxic condition. 

Dilatation and hypertrophy of the heart is common, and in advanced 
cases myocardial degeneration is apt to take place. 

Symptoms. — The outstanding feature of hyperthyroidism is the 
excessive secretion of the gland. The symptoms seem to be largely de- 
pendent upon the amount thrown into the blood-stream; still there is a 
possibihty that there may be a certain perversion of the secretion, though 
if such exists it has not been discovered. It should be kept in view that 
in certain instances where the secreting activity of the gland has been 
markedly curtailed, by surgical means, for instance, even to hypo-func- 
tioning there may still exist some of the symptoms of exophthalmic goi- 
ter, wliich goes to show that other factors may be of decided importance. 
The thymus and other related organs, as well as the sympathetic nerves, 
are not to be neglected. 

Kendall and Plummer (Mayo CUnic) ''believe that the location of 
the active constituent of the thyroid, when it functions, is within the cells 
not of any particular set of organs or portion of the body, but that it is 
a constituent of cellular hfe and activity. Plummer states that the ac- 
tive constituent of the thyroid determines the rate at which any partic- 
ular cell can produce energy, that is, it estabhshes the quantum energy 
which any cell can produce when it is stimulated, either from within it' 
self or from without, so that the thyroid is directly related to the produc- 
tion of energy within the body. He has shown that one-third of one mil- 
ligram of the active constituent of the thyroid increases the basal meta- 
bolic rate one per cent in an adult weighing approximately 150 pounds." 
This shows how important the secretion is not only to all related glands 
but to every cell of the body, and assists in estabUshing a physiological 
basis in the correlation of the symptoms of both hyper- and hypo-func- 
tioning of the organ. 

As a rule the thyroid is not greatly enlarged. The size, shape, and 
consistency varies. It may follow a simple goiter. Many of them are 
soft and jdelding, or cystic; others are hard, of a fibrous resistance, or 
nodular. Probably in the instances where hypertrophy is not discover- 

1. MacCallum, A Text Book of Pathology. 



694 The Practice of Osteopathy 

able there is hyperplastic tissue scattered through the gland. Or it is 
possible there may be an intrathoracic thyroid, or accessory tissue in 
other regions, varying from the root of the tongue to the aortic arch, 
which has become diseased. Generally, both lobes are enlarged, though 
the derangement may be confined to a portion. Often there is pulsa- 
tion and a thrill over the gland. Systolic murmurs are frequent. In 
the earty stage of goiter, tenderness is noticeable due to the distension 
of the capsule. 

The eye symptoms are: widened palpebral fissure or Dalrymple's 
sign; failure of the upper lid to follow the downward movem.ent of the 
eyeball or V. Graefe's sign; insufficiency of convergence of the two eyes 
or Moebius' sign; exophthalmos, which maj^ be unilateral (in about seven- 
tj' five percent of the cases); and rareness of involuntary winking, are 
the principal eye signs. 

Rapid heart action is an early and important symptom. This 
is given by all observers as the most constant of all symptoms. Pal- 
pitation is often disturbing. The pulse is forcible, especiallj^ in the ves- 
sels of the neck. There is generally a low blood pressure. The heart is 
apt to be dilated, and in chronic cases hypertrophy and degeneration are 
often found. 

A fine tremor, eight to ten times a second, is an important symp- 
tom. Tills is usually present and is considered one of the cardinal diag- 
nostic points. 

Profuse sweating, emaciation, muscular weakness, especially 
of the legs, vomiting, diarrhea, a feeling of dyspnea, and poljmria are 
frequent symptoms. Anxietj^, apprehension, headache, irritabihty, and 
fatigue are often early symptoms, but care should be taken that they are 
not entirely dependent upon a neurasthenic state. 

Pruritus may be a distressing symptom. There may be abnormal 
pigmentation. Menstrual derangements are common, especially amenor- 
rhea, owing to the anemia. And there may be various sexual disturb- 
ances. Exophthalmic goiter occurs oftener in women than in men. 

The disease is commonty a chronic one lasting several years, unless 
the morbid cycle can be broken; still there are cases where it appears 
very suddenly and runs a rapid course. 

McCarrison^ says: "Our consideration of the morbid changes met 

with in Graves' disease will have brought into prominence the fact that 

they are indicative of toxic action. The h'mphocytosis, the lymphatic 

hyperplasia, the h^mphocytic infiltration of the thyroid, the liver and 

1. McCarrison, The Thyroid Gland. 



The Practice of Osteopathy 695 

other organs; the chronic toxic inflammatory changes in the thyroid, 
liver and pancreas ; the changes in the muscles, in the nervous system and 
in the adrenals; all these point to a condition of chronic irritation as the 
underlying factor in their production, and to the gastro-intestinal tract 
as the most common source of the toxic irritant. " 

Diagnosis. — The diagnosis as a rule is not difficult. Difficulty 
may arise where there is incomplete development of the disorder. Irri- 
tation of the sympathetic nerves is of the greatest significance, for the 
characteristic symptoms are dependent upon this condition. Neuras- 
thenia, hysteria, paralysis agitans, and tobacco poisoning and alcohol- 
ism may mislead one. The enlarged and active gland, with murmur in 
the majoritj^ of cases, loss of weight, excessive sweating, diarrhea, tremor, 
and tachycardia, even without the eye symptoms, are specially significant. 
The tenderness of the osteopathic lesions is very often noticeable. 

Prognosis. — A great deal depends upon the cooperation of the 
patient. Rest and diet are such important features of the treatment, 
that if the patient is not wilUng to follow instructions, great difficulty will 
be encountered in securing satisfactory results. Adjustment of the 
lesions and elimination of toxins are highly essential, but only in a certain 
number of cases will this suffice. This, however, will usually lessen the 
severity of the condition, and the patient gets along fairly well, but this 
may be far from securing the possible maximum results. The duration 
of the disease is often from five to twenty years, or even longer. And 
the patient frequently dies from some intercurrent disease, particularly 
pneumonia and tuberculosis. Weakness of the heart is the most im- 
portant cause of death. Severe vomiting and diarrhea may so exhaust 
the patient that a fatal termination takes place. Surgical interference 
should not be too long delayed if there is no indication of improvement 
by other means. 

Treatment. — Every case requires individual study, owing to the 
many possible exciting causes, especially those where infections and tox- 
ins play so important a role. The four cardinal features of treatment 
are: adjustment of the osteopathic lesions, rest, diet, and elimination of 
infectious and metabolic poisons. 

Specific adjustment of the upper dorsal spine is primarily essential. 
The work should be definitely and quickly accomplished. Soft tissue 
manipulations amount to but little except as a preparation for the in- 
terosseous adjustment. Do not tire the patient. Often, following ex- 
act adjustment a definite lessening of the severe s3''mptoms will be notic- 
ed. The activity of the thyroid will be appreciably decreased; the heart's 



696 The Practice of Osteopathy 

action slowed; the eye s\aiiptoms less noticeable; the tremor lessened; 
and the strength of the patient improved. Do not treat too often. Once 
a week is far better than every day. But usually twice a week in the ma- 
jority of cases will secure the best results. Then later once in two weeks 
will be the best course to pursue. The tissues are irritable, and require 
time to estabhsh a physiological balance, that if kept constantly excited 
by too frequent or too severe manipulation will increase rather than les- 
len the condition. This, however, does not apply to those cases where 
a certain amount of general treatment is demanded to improve systemic 
tone and overcome intestinal stasis, but even here do not undulj^ tire the 
patient, and keep away from the th3'roid innervation except at stated 
intervals. There is nothing more important in osteopathic therapy, ex- 
cept definite adjustment, than not over-treating. 

The cervical region should be normalized, and the upper ribs and 
clavicles carefully adjusted. But leave the gland alone, for manipulation 
over it further stimulates its function and there is a possibility of rup- 
turing its fragile vessels. Normalization of the entire spine is important, 
owing to its bearing upon interdependent relationship, mechanically and 
physiologicalh^, and the necessity of correcting all metabolic irregular- 
ities. 

Both physical and mental rest are essential. This tends to les- 
sen the excitability of the nerves, conserves the strength, increases the 
metabolism, improves muscle tone, and rests the heart. At least several 
extra hours in bed is always best. Lying down two or three hours 
during the middle of the day will accomplish considerable. In severe 
cases absolute rest in bed until the disorder is under control is impera- 
tive. In mild and moderate cases all excessive fatigue should be avoided. 
Unless such measures are followed the treatment otherwise may not ac- 
complish anything. Stopping short of fatigue is the rule that must be 
followed. 

The diet is important in order that the strength may be increased 
and harmful foods eliminated. If the carbohydrates in the small intes- 
tine are not sufficient, they may decompose into toxic substances that are 
harmful when absorbed into the circulation. An abundance of green 
vegetables and fresh fruit is best. Milk, fermented milk, butter milk, 
butter and cream are allowable. The patient should drink freely of wa- 
ter. Meat should be used sparingly, and avoid tea, coffee, and condi- 
ments. 

Free elimination and fresh air are also important. It is the aggre- 
gate of details that counts so much, particularly in such a toxic and ex- 



The Practice of Osteopathy 697 

citable disease as exophthalmic goiter. The neutral bath (95 to 96 de- 
grees) is better than either hot or cold baths. In such a nervous disease 
as this, suggestion is unquestionably a valuable measure in quieting the 
nerves and improving the mental viewpoint. 

All focal infections, such as often found in the throat, nose, and 
buccal cavity, in the appendix region, gall-bladder, etc., should be erad- 
icated. 

If under carefully controlled treatment the patient does not defi- 
nitely respond within from two weeks to a month, surgical measures 
should be seriously considered. 

Myxedema 

Myxedema is a chronic disease due to loss of thyroid function, and 
characterized by markedly decreased metabohsm, trophic disturbances 
of the skin and subcutaneous tissues, and a cessation of mental develop- 
ment corresponding to the time of the injury of the thj^roid. 

McCarrison restricts the term " cretinism" to those cases where there 
is congenital thyroid deficiency. "After the first year of life, when 
ossification has proceeded to the extent of closure of the fontanelles, the 
case is only distinguishable from one of cretinism by this fact." In 
the child, all the functions are depressed, there is a low temperature, 
the bones do not develop, and the child may become stout. The mental 
development is retarded, and also the sex organs. 

In the adult cases there is the same depressed metabolism. The 
skin is sallow, dry, and increased in thickness. The tongue is enlarged, 
the lips thick, and the feet and hands considerably changed in size. The 
nails may be thickened, and the hair falls out. The abdomen is apt to 
be pendulous. Heavy pads occur below the clavicles and on the chest, 
neck, abdomen, and sexual organs. Usually the thyroid cannot be pal- 
pated. In a few, the gland may be goitrous. 

The mental faculties are sluggish. The speech is slow, and the 
voice more or less changed. Physical exertion is an effort, and the pa- 
tient may have some difficulty in walking. And there is anemia, loss of 
appetite, and poor digestion. The number and character of symptoms 
are innumerable, depending upon the extent of thyroid insufficiency, 
and often upon predisposing and associated disorders. But the essen- 
tial symptoms are those pertaining to the skin, and the mental apathy. 
In children the retarded physical and mental growth is the outstanding 
coiKhtion. Development of the disorder is slow. 

Etiology,— Leoions of the thvroid innervation may cause a lessened 



69S The Practice of Osteopathy 

function of the gland, for correction of the lesions has been followed by 
markedly definite improvement in a number of cases. The disorder has 
followed operation on the gland. In other cases some form of infection^ 
primary or secondary, is probably the cause of the injury and subsequent 
atrophy. In some instances there is evidently a family- tendency. It 
occurs more frequently in women, and in cold than in hot climates. The 
menopause seems to be a predisposing factor. Overwork, anxiety, poor 
nutrition, and conditions that lower tissue resistance, are among the 
etiological considerations. 

In well marked cases the diagnosis is easy. In others the disease 
may be mistaken for nephritis or jaundice. X-ray examination of the 
ossification centers is of decided value. The prognosis, in untreated 
cases, is considered hopeless, the duration being from four to seven years. 
The treatnidnt with thyroid extract, or alpha-iodine, has resulted in mark- 
ed improvement, though in severe cases it must be kept up continuously 
in order to supply the deficiency. 

Treatment. — There have been several well marked cases that have 
responded to the osteopathic treatment. Adjustment of the lesions af- 
fecting the gland, and attention to the general health have been the meth- 
ods administered. The response in a number of children has been most 
notable. In fact, to such an extent that all faculties and functions were 
completely recovered. Even in cases where thyroid extract had been 
administered with comparatively little results, the adjustment of the up- 
per dorsal and cervical lesions, with attention to the diet, elimination, 
and general hygiene, was followed by normalization. 

That the thyi'oid function when deranged, hyperthyi'oidism, hy- 
pothyi'oidism, or otherwise, can often be recovered through osteopathic 
treatment, adds a very important therapeutic measure in the treatment 
of this gland. But in view of the brilhant results secured in hypothy- 
roidism, through the administration of the thyroid extract, one should 
not hesitate to use it if improvement is not otherwise forthcoming. Never- 
theless, the very important point remains that thyroid extract is only 
suppljdng a necessary substance, however essential, to the bodily meta- 
bolism, and does not strike at the essential etiology of the disorder. 

Cretinism 

It should be kept in mind that there are many gradations and alter- 
ations in both hyperthyroidism and hypothyroidism, and that a ''goiter"" 
may present either picture, partly or wholly, or on the other hand may be 
normally functioning. 



The Practice of Osteopathy 699 

MacCallum says: "Unlike the myxedema cases which occur any- 
where and everywhere, regardless of environment or hereditary tainb, 
these people, known as cretins, are found in regions where the condition 
seems to be endemic or inherent in the environment, and we can usually 
trace in their parents or ancestors some similar thyroid defect. " 

This disease is found in various countries, particularly in certain 
parts of Switzerland, Austria, and Italy. McCarrison presents an inter- 
esting study of 203 cases of Endemic Cretinism found in Himalayan In- 
dia. He thinks it is due to infection. There are a few cases in North 
America, probably mostly due to immigration. It is frequently confus- 
ed with myxedema. 

Cretins are of short stature, flat-chested and pot-bellied. The face 
is broad, low forehead, broad nose, prominent cheeks, thick lips, and large 
nose. The development of the bones is retarded; the skin is thickened 
and edematous; the hair is thin, and the nails brittle; the sexual organs 
as a rule do not develop; and in most cases a goiter, sometimes of huge 
size, is present. Most of them are stupid and apathetic; others are dis- 
tinct idiots. Deafness is common. 

There are sporadic and endemic cases, but the same underlying cause 
is probably present. It is claimed that most cases of the former should 
be classed as congenital myxedema. 

Early diagnosis is essential. Removal of the patient from the goiter 
region, and thyroid substance is the treatment given, though results are 
not so marked as in myxedema. 

DISEASES OF THE PARATHYROID GLANDS 
Tetany 

The chnical manifestations of the insufficiency of function of the 
parathjrroid glands is well understood. This came about through the 
study of endemic tetany, and, especially, noting that tetany followed 
operations when the entire thyroid gland was removed. Considerable 
experimental work on animals was next in order, until the discovery was 
made that the thyroid gland and parathyroids are anatomically indepen- 
dent, and that tetany is entirely dependent upon the loss of function of 
the parathyroid glands. Operative tetany is now comparatively rare, 
since the surgeon is parti culai'ly careful not to injure the parathyroids 
in his operations on goiters, though mild forms may occur through damage 
of the tissues or ex-tension of inflammatory processes. 

There are other forms of tetany aside from operative, that occur 
in both adults and children, but instability and insufficiency of the func- 



700 The Practice of Osteopathy 

tion of the glands are basic to all cases. This is the common factor, which 
may be modified by tissue resistance and various hygienic factors. 

In tetany there are paroxysmal, and often painful, contractions of 
the muscles of the extremities. Both sides are affected, and occasionally 
the spasms may extend to other muscles of the body. This is due to an 
abnormal excitability of the nervous system. Probably the secretion of 
the parath\Toids have normally a restraining effect upon the nervous 
impulses, which when removed, or insufficient, or possil^ly perverted, re- 
sults in the tonic spasms. 

Thus the predisposing condition of tetany may be either acquired 
or congenital. Children may be born with defective parathja-oids. 
In such instances there is probably a hypoplasia of tissue, which may 
markedly vary in a series of cases, and give rise to different degrees of 
tetany. Other factors, nutritional and toxic, would, very likely, be im- 
portant exciting causes. Hemorrhages and fibrosis have been noted in 
some cases, that add to the injury of the tissues. 

The blood and nerve tissues in tetany show a decreased amount of 
calcium. It is claimed by some that the abnormal excitability of the 
nervous system is due to the lack of calcium. Noel Paton^ believes that, 
though this maj^ bear some relationship, the parathyi-oids control the 
metabolism of guanidine, and that guanidine intoxication is the cause 
of the symptoms. Guanidine seems to regulate the tone of the skeletal 
muscles, and is closely related to urea. 

Tetany may occur under many conditions: during pregnancy and 
nursing, the infectious and nutritional diseases, the diseases of the thyroid 
and very often gastro-intestinal disorders. There are various exciting 
causes, such as cold, worry, overfatigue, etc. Alcohol, ergot, morphine, 
chloroform, and other poisoning may precipitate an attack. But in all 
these cases the parathyroids are previously damaged. 

The blood supply to the glands is from branches supplying the 
thyroid organ. This intimacy implies that the same sympathetic nerves 
to the thyroid vessels are in control. Probably there are distinct secre- 
tory nerves, as well as vasomotors, that are connected with the upper 
dorsal and cervical sympathetics. Lesions related to the corresponding 
spinal areas probably affect the integrity of the parathyroid function. 

Schafer says: "The parathyroids are amongst the most vascular 
organs in the body. They are supplied each by a special branch of the 
inferior thyroid artery. The sinus-like capillaries come into close rela- 
tionship with the epithelial cells of the gland. The nerves of the parathy- 

1. Paton and Finlay, Jour. Exp. Phys., 1917. 



The Practice of Osteopathy 701 

roids, like those of the thyroids, pass both to the vessels and to the se- 
creting cells. Some evidence has been adduced which seems to show that 
the cell-activity is controlled by the nervous system." 

Hence it would seem that in many cases of tetany, aside from those 
cases due to operative injury and possibly certain congenital instances, 
osteopathic lesions affecting the nerve and vascular supply of the 
organs may so lessen, or pervert, the secreting cells that tetanic states may 
supervene, especially where lowered nutrition, toxins, and infections are 
inciting factors. 

Symptoms. — The tonic contraction of the muscles may last a few 
minutes or may persist for several hours, and are usually confined to the 
hands and feet. The fingers and toes are first affected by the spasm, 
which extends upward toward elbows and knees. This is commonly 
preceded by numbness and more or less pain in the parts. Occasionally 
there is a general ill-feeling, depression, and headache. There may be 
rise of temperature, and some edema of the affected parts. There are no 
mental symptoms. 

The fingers are partly flexed at the metacarpo-phalangeal joints and 
rigidly extended at the inter-phalangeal joints, the thumb is markedly 
adducted and the fingers drawn close together. The wrist may be flexed, 
and in severe cases the elbows flexed and adducted. When the feet are 
contracted the toes are drawn together, flexed, and may overlap, and the 
feet are arched. 

Trousseau's phenomenon. — The spasm is increased by pressure 
over the median or ulnar nerves, or blood-vessels supplying the parts. 
This may also excite an attack. Chvostek's phenomenon. — Percussion 
over the facial nerve will cause quick contraction of the muscles innervat- 
ed. Erb's phenomenon. — The electrical excitabihty of the motor 
nerves is markedly increased. 

Diagnosis. — The characteristic attitude, and the irritability of the 
motor and sensory nerves, make diagnosis easy. It may be confused 
with meningitis, but in tetany there are no brain symptoms, while in 
meningitis there are no characteristic signs of tetany. Generally, there 
is little probability of confusing the disease with tetanus, or hysteria. 

Treatment. — Most cases are of a mild type, and recovery is the 
rule. A great deal depends upon the underlying cause. Malnutrition, 
if long continued, is a very important factor that may readily predispose 
to the disorder. Rickets in children is often a basic consideration. 

Rest, warm baths, and careful inhibitory relaxation of the tissues 



702 The Practice of Osteopathy 

materially assist in controlling the spasms. Attention to the thyroid 
innervation should not be neglected. In indicated cases th>Toid feeding 
ma}^ be of assistance. The diet is of special importance, for many cases 
present some disorder of the gastro-intestinal tract. Meat should not 
be given. Milk is of great value, owing to its calcium content. The 
administration of calcium is highly recommended, for reasons stated 
under etiology. 

Diseases of the Thymus 

There is little known relative to the functions of the thymus. It 
is most active during the growth of the body, attaining its greatest weight 
from the eleventh to fifteenth j^ears, after which it gradually atrophies, 
though a certain amount of the tissue remains throughout life. There 
is usually a gradual atrophy of the organ after puberty, associated with 
increase of connective and adipose tissues. In cases where it does not 
atrophy, there is often hyperplasia of the entire lymphatic system in the 
body. 

There is some relationship between the thjaiius and sexual organs, 
and in experiments where the organ has been removed, ossification is 
delayed, muscular weakness and tremor occur, there is hyperplasia of 
the thyroid, parathyroids, and adrenals, and general cachexia, acidosis, 
and mental deterioration take place. 

The inferior thyroid and internal mammary arteries from above, 
and the pericardiophrenic from below, comprise its arterial supply. The 
nerve supply is from the sympathetic, vagus, and possibly the phrenic. 
In cases of exophthalmic goiter there is frequently an associated en- 
largement of the thymus, which may be shown by the X-ray, due to fail- 
ure of normal involution or a renewal of growth, that msiy be definitely 
influenced by adjustment of the osteopathic lesions. 

In some of the acute infections as pneumonia the thymus may atro- 
phy with some fatty degeneration and increase of connective tissue. 
This also occurs in starvation. If the condition is not of long standing 
recovery will take place. 

In status lymphatieus there is hyperplasia of the thymus and 
enlargement of the lymphoid tissue of the body, and hypoplasia of the 
cardiovascular system. This is a constitutional defect, so that slight 
injuries or infections may prove fatal. It is found in some cases that 
there is hypoplasia of the chromaffin system. Whether this latter condi- 
tion is primary or secondary has not been settled. 

In males the secondary sexual characteristics are not fully developed. 



The Practice of Osteopathy 70S 

The figure resembles the feminine type. The skin is pasty, and the beard 
is lacking or but httle developed. In females the distribution of the hair 
may be somewhat similar to the male sex, slender limbs and chest, and 
disturbances of the menstrual function are noticeable. 

The thyroid, thymus and lymphatic tissues are usually enlarged,, 
while there is hypoplasia of the adrenals and chromaffin system. 

The condition is met with in children who have a weak muscular 
system, increased adipose tissue, pasty complexion, enlarged tonsils and 
adenoids, and frequently are anemic. In children where the thymus is ' 
enlarged there may be excessive lymphocytosis. 

The enlarged thymus may compress the trachea, interfering with 
breathing so that cyanosis and temporary loss of consciousness occur. 
Young children may die in the attack, probably due to compression of 
the trachea or to heart shock. Death in adults has ocurred from 
trifling injuries, shocks, infections, and anesthesia. The underlying cause 
is probably a constitutional weakness. 

Diagnosis is made from the cKnical signs, percussion of the thy- 
mus and the X-ray picture, although these may not be positive. An 
excessive lymphocytosis is suggestive. 

Treatment should consist of good general care of the patient, 
avoidance of injuries and shocks as far as possible, and careful atten-. 
tion to all lesions, especially of the upper chest and neck. By following 
this plan the child may overcome the condition. X-ray treatment is 
being employed with success in some cases. Operations have been 
successful in thymic hyperplasia where it has complicated exophthalmic 
goiter, and also in serious mechanical pressure in children. 

Diseases of the Adrenal Glands 

Experimental work supports the view that the cortex and the medulla 
have separate functions. The medulla of the adrenals is part of the 
chromaffin system, which includes tissue of the same character in the 
ganglia of the sympathetic, the carotid gland, and the accessory gland 
called Zuckerkand's organ. This system is derived from the same cells 
as the s>Tnpathetic nerves. The medulla receives a richer blood supply 
than any tissue in the body. The secretion of the chiomaffin tissue 
is called adrenalin or epinephrin. The blood receives a continuous 
supply of the secretion, which acts upon the small blood-vessels and as- 
sists' in maintaining blood-pressure. It also stimulates glandular tis- 
sue, and has some effect upon voluntary muscle which tends to counter- 
act fatigue. 



704 The Practice of Osteopathy 

The cortex of the adi-enal glands is of epitheUal origin, and is part 
of the so-called interrenal system, which comprises very small masses 
of tissue in the s>anpathetic ganglia. These are located in the hilus of the 
kidney, broad ligament, inguinal canal, prostate, epididymis, and along 
the spermatic veins (Baker). The cortex is the chief glandular tissue 
of the interrenal system. The amount of tissue is not so great after pu- 
bert}' as before. The blood supply of the cortex is not so rich as that of 
the medulla. Abnormal activity is claimed to be the cause of certain 
• sexual derangements, particularly sexual precocity. 

Schafer states that the adrenals are very richly supplied with nerves. 
Each receives no less than thirty-three nervous filaments (KolUker), 
derived in part directly from the splanchnic, in part from the suprarenal 
plexus, which is itself constituted by branches from the cehac, phrenic, 
and renal plexuses. 

We have noted that in lesions (experimental) of the splanchnics a 
few cases presented acute pathological changes, congestion with some 
degeneration of cells, in the adrenals. 

Macleod states that of the many functions of the adrenals that 
which is most dii-ectly associated with epinephrin is the production of 
glucose from glycogen. "When the nervous system is stimulated in such 
a way as to excite the glycogenolytic process, two effects both operating 
in the same dii'ection with regard to the glycogenic function are develop- 
ed : the one, a hypersecretion of epinephrin, which activates the sympa- 
thetic ner^-e endings, the other, the transmission of the nerve impulse 
to the hver cell. " 

Addison's Disease 

This is a rare, chronic disease, more often occurring in men, that is 
chara cterized by muscular and vascular weakness, digestive disturbances, 
and pigmentation. Tuberculosis of the adrenals has been the most 
constant lesion found. In others, syphilis and atrophy have been noted, 
while in a few the condition seemed to be functional. It should be re- 
membered that it is possible that lesions elsewhere in the chromaffin 
system may be the cause in some cases, for all the chromaffin tissues 
secrete adrenalin. 

It is quite likely that in most cases there is some constitutional de- 
fect of the chromaffin system which underlies a certain tendency to the 
disorder. Infections, injuries, physical and mcental strains may lower 
resistance and predispose to the condition. 

Osteopathic lesions of the splanchnics may congest the organs, or 



The Practice of Osteopathy 705 

derange the secretions, or be of such a character that hemorrhages result, 
or fibrous changes follow, that would definitely incapacitate the cells 
and lower resistance. 

Pathologically, the most common change is tuberculosis. Next 
in importance aie atrophy and interstitial inflammation. Cancer of the 
organs has been noted in a few. The adrenal ganglia, the semilunar gan- 
gha, and the solar plexus are often involved. The thyroid gland may 
be altered, which, when affected, is usually decreased in size. Brown 
atrophy of the heart is common. 

Symptoms. — An insidious onset with muscular weakness, lan- 
guor, and weak action of the heart are generally the first symptoms. 
Digestive derangements, such as nausea, hyperacidity, loss of appetite, 
may occur at the same time, or shortly succeed the general debility. 
Headache, insomnia, and depression frequently take place. Pigmenta- 
tion, usually, shortly follows, though there are cases where it is only 
sHghtly noted. The disease is very chronic, of several years duration, 
with periods of intermission. Occasionally, a case runs a very rapid 
course. 

The general weakness is most noticeable. There is low blood-pres- 
sure. The derangement of the stomach and intestines is characteristic. 
And the pigmentation, which at first is light yellow later assumes a 
dark brown color. The pigmentation may be more or less general, but 
the axillae, nipples, genitals, the palms of the hands, and the neck, waist 
or wherever the clothing presses upon the skin, are most pigmented. 
And pigmentation of the mucous membrane may be noted. 

Diagnosis. — In typical cases, where there is esthenia, pigmentation, 
and gastro-intestinal disturbances, the diagnosis is not difficult. Where 
the chnical picture is incomplete, the diagnosis may be very difficult. 

Pigmentation may occur in several other disorders, notably: in 
bronzed diabetes, abdominal mahgnancy, tuberculosis of the peritoneum, 
exophthahnic goiter, pellagra, marked intestinal stasis, stomach ulcer, 
pernicious anemia, certain skin diseases, etc., so great care has to be taken 
in atypical cases. 

Treatment. — General treatment, with special attention to the 
adrenal innervation, diet, rest, and fresh air will accomphsh something. 
In functional derangements, which are very few, recovery may follow. 
But owing to the often constitutional defect, the probability of tubercu- 
lar, syphilitic, and other serious lesions, the prognosis is unfavorable. 



706 The Practice of Osteopathy 

DISEASES OF THE NERVOUS SYSTEM 

DISEASES OF THE NERVES 
Neuritis 

Neuritis is an inflammation of the nerve fibers. It may be con- 
fined to a single nerve, localized; or general, involving a large nmnber 
of nerves, when it is known as multiple neuritis. Osteopathically, there 
are invariably lesions of the osseous or muscular tissues, that corre- 
spond to the nerve fibers involved. The lesion either irritates the nerve 
directly or disturbs the circulation to the nerve. In those cases where the 
osteopathic lesion is not the immediate exciting cause, there will be found 
anatomical irregularities that predispose to the affection. 

Localized neuritis maj^ be due to: Local osteopathic lesions; 
Exposure to cold; septic foci; traumatism; and inflammation of contig- 
uous tissues. 

Multiple Neuritis may be due to: Osteopathic lesions, which are 
associated with infectious diseases, as in diphtheria, typhoid, scarlet 
fever, etc.; prolonged strain or exposure; metabolic poisons, as in dia- 
betes, anemia, tuberculosis, cancer, etc.; alcohol, lead, mercury and ar- 
senic poisoning; and beri-beri, which is probably due to lack of vitam- 
ins, or possibly microorganisms, or carbonic gas poisoning. 

The inflammation may chiefly involve the connective tissue surround- 
ing the nerve — peri-neuritis — or it may involve the deeper structure — in- 
terstitial neuritis. Parenchymatous neuritis is really a degenera- 
tion, due to excessive or prolonged irritation or pressure which cuts the 
nerves off from their centers. This is found in deeply seated osteopathic 
lesions. In experimental osteopathic lesions the first effect is degenera- 
tion of the medullary sheath. This is followed by degeneration of the 
axis cyhnder. The local circulation is notably impaired. An acutely 
inflamed nerve is red and swollen. In peri-neuritis there is an infiltra- 
tion of the nerve sheath with leucocytes. In the interstitial form, 
lymphoid cells are found between the nerve bundles. In the parenchy- 
matous form, inflammatory signs are wanting. The muscles atrophy. 
Associated in all these forms the osteopathic lesion plays either an ex- 
citing or predisposing role, by disturbing nutrition to the tissue and 
thus setting up inflammation, which may lead to-Wallerian degeneration^ 

Symptoms. — Localized Neuritis. — In the case of a sensory nerve, 

1. See Osteopathic Lesion — ^ Journal of American Osteopathic Association. 
May, 1906, and Deason's Physiology. 



The PRA.CTICE of Osteopathy 707 

there is severe pain following the course of the affected nerve, with tender- 
ness upon pressure. This may be followed by loss of sensibility. Troph- 
ic symptoms, such as glossiness of the skin and brittle nails, arise in more 
chronic cases, while in advanced cases, there is wasting of the muscles. 
Sweating, herpes, and occasionally effusion into the joints, occur. When 
a motor nerve is principally affected, muscular power is impaired, motion 
painful and muscular twitchings will occur. Finally contractions, wast- 
ing of the muscles, and even reactions of degeneration, may take place. 
A rare form is the so-called ascending neuritis, in which the inflamma- 
tion extends upward from the peripheral nerves to the larger nerve trunks, 
or even the spinal cord, resulting in myelitis. This occurs most common- 
ly in traumatic neuritis. The duration is variable. Many acute cases 
get well in a few days. Other cases may persist for months and even 
years. 

Multiple Neuritis. — Inflammation involving several nerves which 
are affected simultaneously or in rapid succession. Acute form. — The 
attack usually follows overexertion or exposure to cold and wet, with 
probably some infection. This form is characterized by a chill, followed 
b}^ a rapid rise in temperature which may reach 103 or 104 degrees F.; 
headache; pains in the back and limbs. There is weakness of the legs 
or arms, depending upon region involved, which may be so severe that 
the muscles atrophy. Sensory symptoms are variable. Most cases re- 
cover, though there are instances where the vagi, the nerves to the blad- 
der, rectum, or heart, may be involved. 

Alcoholic Neuritis results from a moderate amount of alcohohc 
drinking, continued over a long time. The first symptoms are usually 
numbness and tingUng in the fingers and toes. Loss of power soon be- 
comes marked, first in the lower, and then in the upper, extremities. 
The extensor muscles are most affected, causing wrist and foot drop. 
Occasionally there is paraplegia. There are hyperesthesia, tenderness 
and pain, especially in the legs. The cutaneous reflexes are commonly 
intact, and the deep reflexes, as a rule, are lost. DeHrium is common, 
and hallucinations or iflusions occur. 

Neuritis from lead poisoning usually present the "wrist drop" 
and "foot drop", with colic, and "blue line" on gums. 

Infectious Diseases neuritis is due to an attack of some infectious 
disease, and may be local or multiple. It is due to toxic materials absorb- 
ed into the blood. It is most common after diphtheria. The sj^mptoms 
presented are those of neuritis due to any other cause. 

Senile neuritis is pro})ably due to arteriosclerosis. 



708 ' The Practice of Osteopathy 

Diagnosis. — As a rule, the diagnosis is not difficult. In the alco- 
holic form in some instances, there may be difficulty, and in cases with 
paralysis, care should be taken. The prognosis of neuritis is generally 
favorable. 

Treatment. — It is very evident that the successful treatment 
of neuritis depends upon being able to ascertain the cause. Rest is im- 
portant in all cases. Rarely has one any difficulty in locating the derang- 
ed structures that are predisposing to the attack; and usually correction 
of these disturbances, which are in the region involve^, will give consider- 
able relief. If the parts are too sensitive to handle insist on absolute 
rest and hot fomentations. The affected area should be kept warm and 
protected. Attention to the diet, and free elimination, are important. 
Metabolic disorders should be corrected, if possible. Give particular 
attention to any septic foci. A change of occupation may be necessary 
in some cases. 

In alcohoHc cases, the alcohol should be stopped as soon as possible. 
Passive movements and massage are helpful, but of course bear no com- 
parison to specific osteopathic treatment. Relaxation of muscles along 
the spinal column and along the course of the nerve will at least give 
temporary relief. 

If contractures and other changes remain after the acute attack, per- 
sistent treatment will generally result in recovery. (See also Painful 
Shoulders, Part I.) 

Sciatica is usually a neuritis of the sciatic nerve, although all pain- 
ful affections of the nerve are termed sciatica. In some cases it is a 
neuralgia when the nerve is swollen and presents an interstitial neu- 
ritis. 

Osteopatliic Etiology. — This affection occurs more frequently 
in males than in females. The usual period for sciatica is from the twen- 
tieth to the fiftieth year and the principal causes are vertebral lesions 
of the lower dorsal and lumbar vertebrae, especially lesions to the fourth 
and fifth lumbar. Occasionally the lesion is a subdislocated innomina- 
tum, a downward displacement of a floating rib or a partial dislocation 
of the femur. Other causes are exposure to cold, contraction of muscles, 
gout, rheumatism and syphihs. Contraction of the pyriformis muscle 
may bring direct pressure on the nerve. Focal infections, arthritis of the 
articular processes of the lower spine, and sacro-iliac and hip-joint 
disease should not be overlooked. In a few cases there are intraplevic 
causes, such as uterine and ovarian tumors, rectal accumulations and 
the fetal head dui'ing labor. Enlarged prostate may be a factor. It 



The Practice of Osteopathy 709 

is possible for the roughened edges of the sacro-iliac joint, internally, 
to irritate the sacral plexus as it passes over and thus keep up the pain. 
This may explain the occasional failure of treatment. 

Symptoms. — Pain in the nerve along its course is the most con- 
stant s^-mptom. The pain is most intense back of the thigh and above 
the hip-joint. The pain radiates downward through the entire nerve; 
it is of an annoying character and walking is especially painful. In 
rare cases there is wasting of the muscles, cramps, herpes and edema. 
In a few cases the neuritis may extend to the spinal cord. 

Diagnosis. — The diagnosis of sciatica is usually easy. Care has 
to be taken in the examination to determine whether the affection 
is primary or secondary. It is difficult, in some cases, to locate the or- 
igin of the disturbance, especially if it is in the lumbar vertebrae, as fre- 
quently a very slight deviation of a vertebra will cause the disease; or 
some focal infection may be difficult to locate; or malformation of the 
fifth lumbar may be present; or asymmetrj^ of the legs or the body be 
a factor. Careful palpation, measurements, and the X-ray are of diag- 
nostic importance. HIp-|oInt disease and sacro-iliac disease can 
generally be easily distinguished from this affection. The lightning 
pains of tabes may simulate sciatica, but then there are other well de- 
fined s3Tiiptoms of the disease. 

Treatment. — Sciatica rarely runs a very long course, though there 
are cases that last for years. The treatment ahnost wholly depends upon 
the cause. If the cause can be determined at once, the probabiHties are 
that severe cases may be relieved by a few treatments. Correction of 
the vertebrae, to relieve impingements to the nerve fibers as they pass 
through the intervertebral foramina, usually constitutes the primary treat- 
ment. Carefully examine the pelvic organs for disturbances. Occas- 
ionallj'- deep treatment over the iliac vessels will be of great help. The 
innominatum, if deranged, should be corrected and all troubles of the 
hip-joint that are found must be corrected. 

Cases of rheumatism and gout should receive their separate treat- 
ments, besides careful manipulations of the affected leg. Rest in bed 
should be insisted upon; this will usually markedly lessen the duration 
of the inflammation. Adjustment of the special points found deranged 
and a thorough treatment, if conditions permit, of the entire leg will be 
beneficial. Hot fomentations applied along the course of the nerve, 
and an inhibitory treatment back of the trochanter will at least give 
temporary relief. Extension of the leg is effective. Placing a patient 
upon his back and flexing the leg and thigh upon the abdomen, at the 



710 The Practice of Osteopathy 

same time keeping the leg straight and the foot flexed, is an effectual 
stretching method. As a rule, sciatica readily responds to osteopathy. 

Neuralgia 

Neuralgia means simply "nerve pain. " The term neuralgia should 
be restricted to such nerve pains as are not caused by structural changes 
in the nerves. In cases where the pain is due to organic changes in the 
nerves, the disease should not be classed as a neuralgia, although it is 
practically impossible to draw an absolute line between functional and 
organic disturbances for the one may gradually progress (pathologically) 
into the other. In neuralgia there is always disturbance of the blood 
supply to nervous tissue, which may be of the character of congestive 
irritation, ischemia or altered states of the blood wherein it contains toxic 
substances or is below normal quality. It is well known that osteopath- 
ic lesions are ver}- common etiological factors. 

Osteopathic Etiology. — Neuralgia is essentially a disease of adults. 
It rarely occurs before puberty or late in life. Women are more prone 
to neuralgia than men and the tendency may sometimes be hereditary. 
Sufferers from neuralgia often present a pecuUar ''nervous temperament. " 

The exciting causes of neuralgia are impairment of general health; 
irritations of the nerve fiber or trunk by a displaced bone, hgament or 
muscle, which may affect the nervous tissue directly by mechanical ir- 
ritation, or indirectly, by the disturbance of its blood supply, or toxic 
agents; exposure to cold or damp; overwork and worry; toxic influences 
of various diseases, as malaria, lead poisoning and alcoholism; irritation 
from carious teeth, and various septic foci. 

Symptoms. — Pain, which is spontaneous and paroxysmal, is the 
most prominent symptom. It may be described as " darting, " " shooting," 
"burning," "stabbing," "boring," etc. The pain is usually unilateral, 
following the course of the sensory nerves, and there are generally tender 
points along the course of the nerve. Especially are there points of 
tenderness near the central end of the nerve, where the displaced struc- 
tures are irritating it. After the pain has continued for some time the 
skin becomes tender, reddened and swollen. The redness and edema 
are supposed to be due to vasomotor changes. Muscular spasms, trophic 
disturbances, skin eruptions, herpes and grayness of the hair are of rare 
occurrence. The duration of an attack varies from a number of min- 
utes to a few hours. 

Neuralgia of the Fifth Nerve. — This is by far the most frequent 
variety of neuralgia, and it is generally due to a displaced atlas or infer- 



The Practice of Osteopathy 711 

ior maxilla. The teeth sinuses, and other possible regions of focal in- 
fections should be thoroughly investigated. Anemia and products of 
metabohsm may be underlying factors. All the branches of the fifth 
nerve are rarely involved. The ophthalmic division is most often affect- 
ed; pain and tenderness being present about the supraorbital notch 
or foramen, the palpebral branch at the outer part of the eyelid, the 
nasal branch, and occasionally an ocular pain will be felt within the eye- 
ball. When the infraorbital hranch is involved, pain and tenderness 
are principally present at the infraorbital, nasal and malar points. When 
the third division is affected, the chief tender places are the inferior 
dental, temporal and parietal points. In nearly all cases of neuralgia 
of the fifth nerve, there is extreme tenderness in the region of the artic- 
ulation of the atlas and the occipital, particularly the side on which the 
fifth nerve is involved. This tenderness in a few cases may be found as 
low as the second or third cervical vertebra. The pain may be so severe 
as to cause edema along the course of the affected nerve fibers, grayness 
of the eyebrows and locks of hair chiefly in the temporal region, and con- 
vulsive twitching of muscles. 

Tic Douloureux is a. vastly exaggerated neuralgia of the fifth nerve 
and is supposed to be a primary affection of the Gasserian ganghon. 
Starting in middle Hfe from no apparent cause it increases in severity 
until it becomes unbearable and suicide is not an infrequent result. 

Many methods to relieve have been tried including destruction 
of the ganglion but with various results. 

Treatment should be the same as in the milder form of neuralgia 
but it will require critical examination to determine the causes which are 
liable to be obscure. 

Cervico-Occipital Neuralgia. — This varietj'' involves the poster- 
ior branches of the first four cervical nerves, affecting the region of 
the posterior part of the neck and head. The pain may extend as far 
forward as the parietal eminence and the ear. The chief tender points 
are about midway between the mastoid process and the spine, between 
the sternomastoid and trapezius (branches of the cervical plexus), and 
a point just above the parietal eminence. This form of neuralgia is chief- 
ly due to subluxation of the upper four or live cervical vertebrae 
irritating the posterior branches of the spinal nerves. A draught of air 
or exposure to cold are common exciting causes. The pain is of a sharp 
lancinating nature or else it is heavy and tense. Tuberculosis of the cer- 
vical spine may be an underlying cause. 

Cervico-Brachlal and Brachial Neuralgia. — In these forms of 



712 The Practice of Osteopathy 

neuralgia the pain is referred to the area suppHed by the four lower cer- 
vical and the first dorsal nerves. The tender points are in the axilla 
along the course of the ulnar, the circumflex at the posterior part of the 
deltoid and points at the lower and posterior part of the neck. The 
lesions exciting this form of neuralgia are usually found in the upper 
dorsal and upper cervical spines, but they may be as low as the sixth 
dorsal or as high as the atlas. As far as neuralgia of the ulnar nerve alone 
is concerned, it can be traced to the seventh and eighth cervical and first 
dorsal, and the lesion may be found occasionally at the fifth dorsal verte- 
bra or rib. How a lesion as low as the fifth dorsal affects the ulnar nerve, 
it is hard to say definitely. There may be fibers directly to the ulnar 
nerve as low as this region, the nerve may be reflexly affected, the vaso- 
motor supply to the ulnar nerve may be disturbed, or possibly the lesion 
interferes with fibers of the deep layers of the back muscles and thus con- 
traction of muscles for some distance above the lesion would affect the 
ulnar and other nerves. The scaleni may be affected and involve the 
plexus. A bursitis may be present (See Painful Shoulders Part I). Fo- 
cal infections are sometimes factors. 

Trunk Neuralgia. — This includes dorso-intercostal and Imnbo- 
abdominal neuralgia. The former, dorso-intercostal neuralgia, affects 
the intercostal nerves from the third to ninth dorsal, and is character- 
ized by pain along the intercostal spaces, or in a few of them. The 
pain may be bilateral and sjTiimetrical, which usually shows a vertebral 
lesion. Three points of tenderness are usually noted, viz., near the 
median line in front, and midway between these two points in the mid- 
axillary fine. The pain is usually dull with acute exacerbations. Les- 
ions of the vertebrae and ribs in the locality affected are by far the 
principal causes. Cold, exposure, strains, etc., are exciting causes of 
every-day occurrence. When the pain is bilateral and s\aiimetrical the 
lesion is usually in the vertebra; when unilateral the rib alone may be 
involved. The most common lesion is a crowding together of the ribs 
anteriorly at the fifth and sixth interspaces. Carefully exclude a pos- 
sible tuberculosis of the spine or ribs, aneurism, etc. 

The pain of herpes zoster is not neuralgic, but neuritic, involving 
the posterior spinal ganglion. Pleurodynia, strictly speaking, is neural- 
gia of the pleural nerves, and not of the intercostals, but a deranged rib 
over the region of the pain is commonly the cause of the pleurodynia. 

Lumbo-abdominal neuralgia involves the posterior branches 
of the lumbar nerves. Tender points are found near the vertebrae, 
middle of the iliac crest, lower part of the rectus, and in the male occas- 



The Practice of Osteopathy 713 

sionally in the scrotum, in the female in the labia. These are often bi- 
lateral and are usually of a constricting nature. The ihoscrotal branch 
is the one most commonly affected. 

Subluxation of the vertebrae, and other lesions, as contracted 
muscles, are found along the lumbar vertebrae, and even as high as the 
lower dorsal vertebrae. Also lesions are found at the lumbo-sacral ar- 
ticulation. Pelvic disease is also a cause. 

A downward displacement of the lower ribs, eleventh and twelfth, 
is a common disorder and may be the cause of severe neuralgic pains 
in the region of the ihac fossae. It may simulate ovarian inflammation, 
renal colic, or even appendicitis if on the right side. And septic kidney 
has been wrongly diagnosed from these lesions. In fact it may be a cause 
of inflammation of the deeper structures, such as the ovary and Fallopian 
tube. 

A subluxation of the vertebrae at the fourth and fifth dorsals may 
cause severe neuralgic pains in the epigastrium. 

Neuralgia of the Spinal Column. — According to medical writers 
this is especially found in weakly women and after concussion of the spine ; 
that it is a troublesome symptom in hysteria, and in many cases it is due 
to a reflex stimulus from diseased viscera. Most of this is undoubtedly 
true, but they have not found out the real significance of these neuralgic 
pains. The various tender points along the spinal column are of para- 
mount importance to the osteopath as a guide to his diagnosis; not 
only in certain cases, but in nearly every case. The tender points are 
not due, in nearly everj^ instance, to reflex stimuli from diseased organs, 
but these tender points are often the result of a local lesion, and are many 
times the cause of the disorder to the diseased viscus. The neuralgic 
pains are simply a symptom that a lesion exists in the immediate locaUty. 

Neuralgia of the Sacral Region and Coccygodynia. — This 
form involves the nerves in the sacral and coccygeal regions. The nerves 
between the bone and the skin are affected. The cause of the pain is 
generally due to derangement of the articulation of the lumbar and 
sacrum, and to severely contracted muscles over the sacral foramina; 
also to lower lumbar lesions. It may be a reflex from various possible 
disorders of the organs and tissues of the pelvis. In coccygeal neuralgia, 
the coccyx is commonlj^ displaced in any one of the various displacements 
that are liable to occur. Special attention should be given to the fibro- 
articulation of the coccyx, and to the status of the lumbo-sacral and in- 
nominata. In adjusting the coccyx, place forefinger in rectum up to 
proximal end of coccyx, and with thumb externally over the section, 
exert traction until articulation is released; then adjust. 



714 The Practice of Osteopathy 

Neuralgia of the Legs and Feet. — This includes the crural form, 

in which the front of the thigh is the seat of the pain ; also the form in 
which tender points are found along the course of the sciatic nerve. The 
latter form is quite a common one, although sciatica is rarely a neuralgia. 
It is a neuritis and will be found classed under that heading. The tender 
points presented are the lumbar, sacro-iliac, gluteal, peroneal, maleolar 
and external plantar. The various neuralgic pains of the legs and feet 
are generally due to lesions of the lumbar, pelvic and thigh regions, 
and to weak arches. Metatarsalgia occurs when the fourth metatarso- 
phalangeal articulation is partially dislocated. Neuralgia in the heel, 
ball of the foot and toes may be due to local causes or to lesions higher up. 
Aside from the above care should be taken that there are no toxic factors 
that may be exciting causes. 

Visceral Neuralgia. — This is a term apphed to neuralgia of the gas- 
tro-intestinal tract, the kidneys, and the various pelvic organs. 

Diagnosis and Prognosis of Neuralgia. — Neuralgia is to be diag- 
nosed chiefly from nem-itis, rheumatism, and the effects of severe pres- 
sure upon the nerves. In neuritis there is oftentimes a symmetrical 
affection, while in neuralgia there is a unilateral distribution and there 
are many remissions and intermissions and a varying of the pain from one 
place to another. In severe forms of neuritis, anesthesia succeeds the 
hyperesthesia of the sensory nerves. In cases of severe pressure upon 
nerves, the pain is continuous and neuritis will soon be manifested. In 
rheumatism the pain is locahzed in muscles or groups of muscles and 
does not follow the course of the nerve. The pain is increased by motion. 

The prognosis is generally favorable, no matter how severe the 
attack. The prognosis is influenced onh^ by the age of the patient and 
the cause. 

Treatment of Neuralgia. — Consists, first, in the control of the 
paroxysm and, second, in the removal of its cause. In controlUng the 
paroxysm, frequently one will be able to remove the cause. In a large 
majority of neuralgias the cause is directly due to a displaced tissue, 
generally a bone or muscle in the locality affected; often all that is neces- 
sary in order to perform a cure is to adjust the disordered tissue and the 
pain will cease. This usually can be done immediately, although there 
are cases which require several treatments before an adjustment of the 
parts can be accomplished; besides, in acute cases the involved region 
will be so tender that an attempt to correct the tissues sufficiently to re- 
lieve the paroxysm will be unbearable to the patient. In such instances 
when the cause cannot be removed at once, firm pressure or inhibition 



■ii*i«^': 



The Peactice of Osteopathy 715 

over the involved nerves for a few minutes and local application of hot 
packs generally disperse the pain for the time being. The rules of hygiene 
should be observed in all cases. 

The best time to remove the cause of neuralgia is between the 
attacks when the tissues are not as tender or contracted to such an ex- 
tent as during the paroxysm. A diagnosis can then be made much more 
easily, and the tissues adjusted with less pain to the patient. 

The details (as to the locality treated) for each form of neuralgia 
will be found under the discussion of each variety. The general health 
and diet should be considered. Peterson^ says: "Morphine is, among 
the alkaloids, the most frequent cause of insanity. It is a sad commen- 
tary on the heedlessness of some medical men, but the family physician 
is responsible, in almost every case, for the development of the mor- 
phine habit and its far reaching consequences.. It should be looked upon 
as a sin to give a dose of morphine for insomnia or for any pain (such as 
neuralgia, dysmenorrhea, rheumatism) which is other than extremely 
severe and transient. " 

Diseases of the Cranial Nerves 

Olfactory Nerves. — This nerve may be affected at various points 
from its origin to distribution. The disturbances may produce hyper- 
osmia, or anosmia. The lesions may be tumors, injuries to the head and 
various diseases of the brain, or diseases of the nasal mucous membrane. 

The treatment of the nerve (beside treating the disease causing the 
disturbance) is to the cervical region with a view to controlling the blood 
supply. 

Optic Nerve and Tract.^ — The retina, optic nerve, chiasma and 
optic tract may be affected by various lesions. 

The affections of the retina are organic or functional. Under or- 
ganic there is hemorrhage and retinitis. Retinitis may be due to several 
diseases, as syphilis, Bright's disease, anemia, etc.. Functional includes 
toxic and hysterical amaurosis, tobacco amblyopia, nyctalopia, hemeral- 
opia and retinal hyperesthesia. 

Included in the lesions of the optic nerve, are optic neuritis and op- 
tic atrophy. 

Under lesions of the chiasma and tract are diseases of the chiasma 
and unilateral regions of the tract. Lesions of the tract and centers may 
be found in the tract itself,'^in the optic thalamus and the tubercula quad- 

1. Nervous and Mental Diseases, p. 622. 

2. See Diseases of the Eye, Part I. 



716 The Practice of Osteopathy 

rigemina, in the fibers of the optic radiation, in the cuneus, and in the an- 
gular gja-us. 

A brief summary, oiAy, has been given of the lesions found, it being 
the idea not to dwell upon symptoms, morbid conditions, etc., but to 
bring out essential osteopathic features in regard to the cranial nerves. 
For the various effects of these lesions and points of diagnosis, the 
reader is referred to the various works on nervous diseases. 

Lesions peculiar to osteopathic practice, that affect the optic 
nerve and tract, are found chiefly in the upper and middle cervical verte- 
brae. The disorders to these vertebrae may involve fibers of the optic 
nerve directly — those that are supposed to originate in the cervical spine; 
they involve the retina and optic nerve by way of the fifth, as claimed by 
some; and the above lesions especially affect the blood supply to the op- 
tic nerve and tract, either interfering mechanically with the blood-ves- 
sels or obstructing and irritating vasomotor nerves. The most common 
lesions are sub-dislocations of one or all of the three upper cervical verte- 
brae. Still, lesions may be located as low as the third or fourth dorsal 
vertebra, which may influence vasomotor and s>aiipathetic nerves, or the 
lymphatics. The three or four upper ribs should also receive due con- 
sideration. 

Motor Oculi. — Lesions of the third nerve may affect its center 
or the course of the nerve. These lesions produce spasms or paralysis. 

The onlj^ waj^ that we can control the motor oculi is by way of the 
superior cervical s^nnpathetic ; also, it has a connection with the fom'th, 
fifth and sixth nerves, and w^e can influence it to some extent by direct 
treatment to the ej^eball and orbital muscles. It should be remembered 
by the osteopath that many of the lesions affecting the cranial nerves, 
are found upon post mortem examination, to be the effect of lesions in 
the spinal region; that many predisposing lesions are the disordered ana- 
tomical spinal tissues; as for instance in the third nerve, derangements 
of the atlas or axis may affect the nerve s,>Tiipathetically (reflexly), or pos- 
sibly by direct fibers, and produce the secondary effect — the so-called 
primary lesions of other schools — at the center or in the course of the 
nerve. 

Patheticus. — This nerve may be involved by tumors at its nucleus, 
or as it passes around the outer surface of the crus into the orbit. Aneur- 
isms or the exudation of meningitis miaj^ also compress its fibers. This 
nerve is purely motor, although it receives a few recurrent sensory fibers 
from the fifth nerve. 

This nerve is controlled osteopathically, principally at the superior 



The Practice of Osteopathy 717 

cervical sympathetic. It has connections with the sympathetic by way 
of the cavernous plexus. 

Trigeminus. — Lesions of this nerve are found in its nucleus and 
in the pons, and include sclerosis, hemorrhage, disease and injury at the 
base of the skull, tumors, aneurisms, inflammation of the nerve, and sub- 
dislocations of the upper three cervical vertebrae, or the inferior max- 
illary. 

This nerve is an extremely important one from an osteopathic point 
of view, as it has a vasomotor influence over various vessels of the head 
and face, and secretory fibers to the lachrymal, parotid and submaxillary 
glands; also, it controls mastication, and to some extent deglutition, 
and influences hearing (tensor tympanum muscle). Diseases of the na- 
sal mucous membrane and disease of the anterior portion of the eyeballs 
are largely due to the vertebral sub-dislocations and to derangements 
to the inferior maxifla. Our principal work upon this nerve is at the 
upper cervical vertebrae, the inferior maxilla, and the deeply contracted 
muscles in the upper cervical region. For the facial points of treatment 
see neuralgia of the hfth nerve. This nerve is closely related to the 
sixth, seventh, eighth, ninth, tenth, eleventh and twelfth nerves. Par- 
ticular emphasis is given to the importance of treating this nerve in na- 
sal catarrh and in eye diseases of the anterior portion of the eyeball. It 
contains trophic fibers to the eye, sensory fibers to the sclerotic coat and 
iris, and vasomotor fibers to the choroid plexus. 

Abducens. — This nerve is especially liable to be affected by tumors 
and meningitis. It is controlled osteopathicalty at the superior cervical 
sympathetic, being connected with the sympathetic at the cavernous, 
plexus. 

Facial. — Lesions may occur in the cortical centers of the nerve, 
the nucleus and the nerve trunk. Paralysis of the facial nerve occasion- 
ally occurs (Bell's paralysis) ; also facial spasm may occur. This nerve 
is controlled at the stylomastoid foramen. Lesions to the atlas, anter- 
iorly or laterally, are commonly found. In the region of the stylomas- 
toid foramen, the nerve communicates with the great auricular of the cer- 
vical plexus, the trifacial, the vagi, the glosso-pharyngeal and the car- 
otid plexus of the sympathetic. The facial nerve may be affected directly 
as it passes above the angle of the jaw. 

Nearly every case of Bell's paralysis can be cured by osteopathic 
treatment. There are usually lesions to the upper two or three cervicals. 
Correction of the cervical vertebrae and massage of the paralyzed nmscles, 
with care of the general health, will suffice, provided there is not an ex- 



718 The Practice of Osteopathy 

tensive central lesion. Although the disease may be due to syphihs, 
meningitis, tumors, etc., the most frequent causes are lesions of the atlas, 
axis, and third cervical and exposure to cold. The cold produces a 
neuritis in the Fallopian canal, and deep treatment beneath the angle of 
the jaw is effective. The prognosis of BeU's paralysis is favorable. 

Auditory. — Lesions^ affecting this nerve may occur anywhere from 
its cortical center to its distribution in the cochlea and vestibule. Dis- 
orders resulting from lesions to this nerve are nervous deafness, auditory 
hyperesthesia, tinnitis aurium, and Meniere's^ disease. 

The control of the nerve and the treatment of lesions affecting it, 
are effected principally at the first and second cervical vertebrae. The 
atlas is especially apt to be subdislocated anteriorly or in a rotary man- 
ner. The condition of the upper dorsal region should also be carefully 
examined, as vasomotor nerves to the ear may be impinged at this point. 
The auditory connects with the fifth, sixth and seventh nerves. 

Glosso-Pharyngeal. — This nerve may be affected by tumors, 
degenerations, meningitis and various lesions. It is often very hard to 
determine exactly the pathology, on account of its various connections 
with other nerves, the vagi, facial, spinal accessory, olfactory and optic 
nerves. 

This nerve is chiefly controlled at its exit at the jugular foramen. 
Osteopathically, lesions of the cervical vertebrae and upper dorsal 
vertebrae affect it. The deep muscles of the anterior and lateral regions 
of the neck and subdislocations of the atlas especially affect the nerve. 

Pneumogastric. — On account of its extensive distribution, and the 
importance of its functions this is one of the most important nerves in 
the body. It distributes fibers to five vital organs — heart, lungs, stomach, 
liver and intestines — and to other organs of secondary importance. This 
nerve is associated with deglutition, phonation, respiration, circulation 
and digestion. 

Hemorrhages, softening, etc., may involve the nucleus of the nerve, 
while the trunk may be impinged by tumors, thickened meninges, aneur- 
ism of the vertebral artery and subdislocation of the upper five or six 
cervical vertebrae, chieflj^ the atlas. 

The nerve is most easily controlled at its exit from the foramen. 
Inhibition of the suboccipital region, between the mastoid process and 
transverse process of the atlas, will influence the nerve markedly, proba- 

1. See Ear Section, Part I. 

2. R. D. Emery reports a case of Meniere's disease as cured. A. O. A. Case 
Reports, Series IV. 



The Practice of Osteopathy 719 

bly reflexly; also direct treatment may. be given the nerve as it passes 
along the anterior part of the neck near the trachea. The superior laryn- 
geal branch may be treated below the great cornu of the hyoid bone and 
attention is particularly called to this in all affections of the throat where 
coughing is a feature; the inferior laryngeal, at the inner side of the low- 
er part of the sternocleidomastoid muscle. The inferior laryngeal 
nerve may be affected by dislocation of the first and second ribs, produc- 
ing pressure upon the nerve as it winds about the subclavian vessel. 
Fibers of the nerve have been traced to the spinal accessory nerve, as low 
as the sixth and seventh cervical vertebrae; consequently, lesions to 
the vagi nerves may occur anywhere in the cervical region. 

Spinal Accessory. — Lesions of this nerve may cause paralysis or 
spasms to the structures to which it is distributed. The lesions consist 
of subdislocations of cervical vertebrae, chiefly the upper three or four. 
The nucleus may be involved by wounds, abscesses, caries of the verte- 
brae, tumors and meningitis. These lesions may also involve fibers of 
the trunk. 

The special points of control of the nerve are at the jugular foramen, 
the sixth and seventh cervicals and the second, third and fourth cervicals. 

Torticollis or Wry-neck is spasm of the muscles of the neck sup- 
plied principally by this nerve. There will be found either derangements 
of the middle or lower cervical vertebrae or the muscles are swollen 
from exposure to cold or from a blow. Sometimes the lesion is in the up- 
per dorsal. The disorder is mainly a neurosis and, unless it has become 
chronic, the prognosis is favorable, and even in chronic cases, often con- 
siderable benefit can be obtained. 

Hypoglossal. — This nerve may be affected by cortical, nuclear 
and infra-nuclear diseases, as well as by subdislocations of the upper 
cervical vertebrae. It communicates with the superior cervical ganglion, 
the vagi, the upper cervical nerves and the gustatory branch of the fifth 
nerve. We control the nerve at the anterior condyloid foramen and 
at the superior cervical ganglion. 

Diseases of the Spinal Nerves 

Cervical Nerves.^The great occipital nerve may be controlled 
at a point on the occiput between the mastoid process and the first cer- 
vical vertebra. The small occipital and the great auricular nerves 
may be controlled at a point just behind the mastoid process. The 
great auricular nerve and the frontal branch of the trigeminus nerve 
meet over the parietal protuberance. The preceding points are the 



720 



The Practice of Osteopathy 



places where one may inhibit the nerves and control certain headaches 
or neuralgic attacks, although subdislocations of the upper cervical ver- 
tebrae, or contracted muscles between the atlas and occiput are usually 
the cause of such disturbances. Adjustment of the lesion will usually 
correct the disturbance. Carefully exclude possible caries or tumors. 

Treatment of the upper cer^ncal region, by relaxing muscles and 
correcting deranged vertebrae, constitutes the principal treatment of an 
ordinary headache. It is best to have the patient flat upon his back 
and the osteopath stand at the head of the patient, and, first, thoroughly 
relax these contracted muscles or correct the derangement of the verte- 
brae; then after the foregoing has been accomplished, give an inhibitory 
treatment of the sub-occipital region. In inhibiting, place the fingers 
over the contracted and tender tissue; hold tightly for several minutes, or 
at least until the tissues have thoroughly relaxed. Many times one will 
be able to detect a slight twitching underneath the fingers, and when 
such is felt, he knows at once that the headadche is reheved. In inhib- 
iting at any point along the spine, seek the contracted fibers and tender 
points and inhibit exactly over the area. Headaches that are due to a 
disturbed circulation of the brain, may be relieved by this inhibitory treat- 
ment in the suboccipital region. The treatment tends to reestablish 
a normal circulation to the brain. Although the large vascular areas 
such as the splanchnic, should, if possible, be normahzed. Headaches 
may also be due to lesions at various points along the spine and ribs, and 
a correction of such points is necessary in order to cure the affection. A 
place often found involved is the upper dorsal region. Reflex headaches 
can be cured only by relieving the irritation. The treatment to the head 
would only be temporary. In headaches of the chronic type it is well to 
examine the scalp and if not freely movable over occipital region it may 
be adherent to the skuU and cause pressure on the occipital nerves. 

Lesions to the phrenic nerve usually occur in the region of the third, 
fourth and fifth cervical vertebrae. The lesion may be due to a deranged 
vertebra, or to disease of the membrane of the cord, or of the anterior 
horn of the gray matter (See Hiccoughs). 

Paralysis of diaphragm from the phrenic may be single or double. 
When single it is not very noticeable. When double, respiration must be 
carried on by the intercostals and accessory muscles. When quiet, the 
patient may not notice it but on exertion there may be temporary 
dyspnea. Bronchitis with its constant coughing is a bad complication. 

Various disorders of the phrenic nerve are principally treated in 
the area of the origin of the phrenic nerve. Tumors, aneurism, caries, 
and neuritis are possible complications. 



The Practice of Osteopathy 721 

Lesions to the brachial plexus are usually derangements of the 
cervical or upper dorsal vertebrae. Focal infections should not be over- 
looked. Direct injuries, contraction of muscles, a deranged clavicle, 
a cervical rib, or a dislocated shoulder are to be thought of. (See, also. 
Painful Shoulders, Part I) The X-ray as a diagnostic aid may be invalu- 
able. 

In obstructions to the musciilo-cutaneous nerve, the power 
to flex the fore-arm upon the arm is greatly impaired. The lesion is most 
likely to be found between the fifth and sixth cervical vertebrae. 

Clinicalty, the median nerve is of special interest from the fact that 
atrophy of the muscles of the ball of the thumb, which is pathognomonic 
of progressive muscular atrophy, may be caused by an affection of this 
nerve. The lesion is usually from the third to the seventh cervical verte- 
brae. 

Lesions of the silnar nerve may arise between the sixth and seventh 
cervical vertebrae, but are oftentimes found as low as the fifth dorsal, 
especially at the fifth rib on the side affected. 

Lesions of the clrcnniflex nerve may be found in the lower cervical 
vertebrae, but are commonly caused by dislocations of the humerus and 
clavicle. 

Lesions of the suprarscapular nerve occur most frequently from 
the fifth to sixth cervical vertebrae. 

The posterior thoracic may be lesioned at the fifth or sixth seg- 
ments, or by pressure injuries to the serratus magnus. 

Dorsal Nerves. — The essential osteopathic points of the dorsal 
nerves have been considered under intercostal neuralgia. It might be 
stated that the posterior fibers of the sixth and seventh dorsal nerves sup- 
ply the skin of the pit of the stomach. This is of value, clinically, as 
severe pains in the epigastric region which may result from impingement 
of these nerves, are supposed by the patient to be due to stomach dis- 
order. 

Diseases of the liver may be manifested by pains in the region of the 
right scapula. It has been suggested that the stimulus passes from the 
liver up the pneumogastric to the spinal accessory and down the spinal 
accessory to the trapezius muscle and thus causes the "liver pain." 

Intercostal neuralgia is more common on the left side of the body. 
The intercostal veins of the left side empty into the left superior inter- 
costal vein or the left azygos. Thus the blood, to reach the vena cava, 
is obliged to take a circuitous route and stagnation is more likely to oc- 
cur than on the other side. 



722 



The Practice of Osteopathy 



The glandular structure of the mammary glands is supplied by in- 
tercostal nerves from the third to the sixth interspace. Lesions here will 
cause various diseases of the breasts and adjustment will cure many of 
them. 

Lumbar Nerves. — The lumbar nerves may not only be deranged 
by various growths, inflammatory processes and abscesses in the abdomen, 
but by lesions, infections, parturition, and developmental defects of the 
lumbar vertebrae. Tuberculosis of spine, sacro-iliac and hip joints, is 
not rare. In doubtful cases utilize the X-ray plate. 

Lesions in the region of the first lumbar may affect the iliohypo- 
gastric and ilio-inguinal nerves and causes various irritations of the 
penis, scrotum, labimii and thigh. Also, the perineal region may be in- 
volved, as well as connecting branches of these nerves to various visceral 
nerves underneath. 

The genital organs may be affected by lesions to the genitocrural 
and external cutaneous nerves, caused by vertebral lesions of the sec- 
ond and third lumbar vertebrae. The latter nerve may be irritated by 
pressure underneath Poupart's hgament. 

Lesions at the thhd and fourth lumbar vertebrae and sacroiliac 
articulation may affect the obturator nerve. 

Sacral Nerves. — Lesions to the sacral nerves are especially liable 
to occur when an innominatum is subdislocated, as that changes the 
relative position of the femur with the body and causes impingement 
to the sacral nerves. Contraction of the pelvic and thigh muscles also 
affect sacral nerves. Other lesions to the sacral nerves may be located 
at the fifth lumbar and sacrum. It should be remembered that the 
centers of the sacral nerves are in the lower dorsal and upper lumbar re- 
gion. Various lesions to the sacral nerves may be caused by pelvic in- 
flammation, compressions b}^ growths, and injuries and contractions of 
muscles within the pelvis. }Sciatica has been described under neuritis. 



The Practice of Osteopathy 723 

GENERAL AND FUNCTIONAL DISEASES 

Paralysis Agitans 

(Shaking Palsy) 

Definition. — A chronic, nervous disease, characterized by tremors, 
muscular weakness, muscular rigidity and alterations in the gait. 

Etiology. — The disease usually commences after forty years of age, 
but occasionally it occurs from the thirtieth to fortieth years. It is 
more frequent in males than in females. Heredity seems to have but 
Httle influence in the cause of the disease. Among the principal causes 
are phj-sical injuries, exposure to cold and wet, emotion, worry, alco- 
holism, sexual excesses and acute diseases. Physical injury, in conjunc- 
tion with exposure to cold is the best determined cause. Disorder of 
the vertebrae of the cervical or dorsal regions, or of the upper and middle 
ribs, can generally be found. Traumatic influences probably affect the 
nerve centers, causing a disturbed innervation, either by the direct effect 
of the deranged structures upon the nervous tissues or obstructing nutri- 
tive channels to the nervous tissues. 

In most cases no changes have been observed in the central nervous 
system or in the sympathetic ganglia. Some observers have noted in- 
duration of the pons, meduUa and cord, but these changes may be due 
to seniHty or to the indirect consequences of the long disturbance of 
function. In a few cases, interstitial sclerosis of the peripheral nerves is 
observed; these are probably secondary changes. Osteopathic exper- 
ience regards paralysis agitans as an affection of the central nervous 
system, due to a disordered structure in the locality affected. 

Symptoms. — The onset is usually gradual, but may come on quite 
suddenly after exertion. The initial symptoms are usually tremor, 
stiffness or weakness in one hand. In rare cases, at first there maj^ be 
neuralgic pains, dizziness and symptoms of a rheumatoid nature. The 
tremor can be controlled by the will at the onset of the disease. The 
affection gradually extends until an entire side or the upper or lower 
limbs are involved. At this advanced stage of the disease, a peculiar 
muscular rigidity of the involved region takes place. Muscular weak- 
ness comes on at about the same time as the rigidity, and the loss of 
power varies much in degree. The condition is most marked in the fingers 
and hands, whence it extends to the arms and legs. It commonly passes 
from the right arm to the right leg, then to the left arm, and then to the 
left leg. At this stage the movement between the thumb and fingers is 



724 The Practice of Osteopathy 

like that of crumbling bread. The writing is greatl}^ affected and in 
time it is impossible to write. The trembhng may be so violent as to 
prevent sleeping. There is occasionally an intermission of days in the 
tremor. 

On account of the rigidity of the muscles, the patient assumes a 
characteristic attitude and gait. The position of the body is that of a 
tendency to go forward, the head is bent forward, the back ciu'ved out- 
ward, the arm bent at the elbow and held away from the body, and the 
kness so close together that they rub in walking. The gait is a "pro- 
pulsive" one, and when once started in a forward walk, the patient's 
gait becomes more and more rapid and he cannot stop until he comes 
against some object. The expression of the face is stiff and mask-like, 
the speech slow and monotonous and the voice shiill. The patient is 
generally restless and troubled with insomnia. The general health is in 
fairly good condition. Reflexes are usually normal. The intellect is 
generally retained, although the physical ailment may cause mental de- 
pression. 

Diagnosis. — Is usually easy and can oftentimes be made at a glance. 
Disseminated sclerosis has a tremor, but is shown particularly in vol- 
untary movements. The speech is scanning and the gait ataxic. The 
disease begins in the lower extremities, the attitude is different from that 
of paralysis agitans, and there is nystagmus. In chorea the movements 
are general, irregular and more intermittent, and it particularly involves 
muscles of the face. Also chorea is a disease of children and young 
adults. 

The tremors of old age, hj^steria, and certain toxic conditions due 
to tobacco, alcohol, etc. are generally easily diagnosed. 

Prognosis. — The disease does not necessarily shorten life; the pa- 
tient oftentimes dies with some intercurrent disease. Improvement 
usually results from careful, prolonged treatment. Early treatment, of 
course, will give the most satisfactory results, and occasionally, if taken 
very early, the case can be cured. 

Treatment. — A most careful examination of the physical struc- 
tures of the patient should be made, particular attention being paid to 
the cervical and dorsal vertebrae, the upper and middle ribs and the 
muscles along the spinal column. All irregularities found should be 
corrected if possible, and strong, thorough treatment given to the region 
of innervation of the affected parts. Traction of the rigid areas is of 
some value. Treatment of the arms and legs will also be of aid. All 
mental strain and physical exhaustion should be prevented if possible. 



The Practice of Osteopathy 725 

General hygienic measures are to be employed. The life of the pa- 
tient should be quiet and regular. Bathing, fresh air, massage and 
out-door hfe will aid in improving the general health. Persistent 
treatment will retard the progress and frequently improve the general 
condition. Simple and hysterical tremor must not be confounded with 
that of paralysis agitans. E. Ashmore^ reports an interesting case which 
shows about what may be expected under treatment. 

Acute Chorea 

(St. Vitus Dance) 

Detanition. — A functional disorder of the nervous system, chiefly 
affecting children, more than twice as frequent in females as males; 
characterized by irregular involuntary muscular contractions, often 
slight mental disturbance, and KabiHty to endocarditis. 

Osteopathic Etiology. — The disease affects children of all stations, 
but is more common among the lower classes. The greater number of 
cases occur before the age of twenty. It sometimes develops during the 
early months of pregnancy, when it often assumes the maniacal type. 
Chorea is frequently associated with endocarditis and rheumatism and 
delayed menstruation. It occasionally follows infectious diseases of 
childhood, especially scarlet fever. Fright, mental worry, sudden grief 
and overstudy may bring on an attack. Children of neurotic stock are 
more susceptible. Heredity plays some part as a predisposing cause. 
Reflex irritation from worms or from genital irritation has a slight in- 
fluence upon the disease. Overwork in school is an important factor. 
Derangement of the anatomical structures, involving the nervous 
system along the spinal column, is the most common predisposing cause. 
Most of the anatomical displacements are found in the cervical verte- 
brae, although the upper dorsal may be involved. 

Pathologically, as yet, no constant anatomical lesions have been 
found. Emboh occur in some cases, but this might be expected, as endo- 
carditis so frequently occurs as an effect and not the cause of chorea. 
"In cases not rheumatic, the most probable explanation of the symptoms 
is to be found in vascular changes, having their origin in disturbed nu- 
trition. " (Holt) According to osteopathic theories and investigations, 
the disease is due to various irritations to the spinal centers and nerves 
of the affected region. The disordered nerve cells may be the result of 
direct pressm-c, hyperemia, anemia, etc., and the action upon the brain 

1. A. O. A. Case Reports, Series IV. 



726 The Pra^ctice of Osteopathy 

centers is possibly a reflex act. Of late acute chorea is regarded by 
some as an infectious disease. 

Symptoms. — In the majority of cases the muscular movement is 
not severe. They are purposeless and the cliild appears awkward. Rest- 
lessness, disturbed rest at night, crying spells, pain in the Kmbs, head- 
ache and irritability, are some of the premonitory sjanptoms. In mild 
cases one hand, or the hand and face, are involved. Occasionally there 
is some difficulty in talking. The irregular, jerky movements are char- 
acteristic of this disease. The child is anemic, and the muscles are weak. 
In severe cases the movements are general, the power of speech is lost, 
and the patient is unable to get about. The condition usually occurs 
after one or more mild attacks, although it may occur primarily. Dur- 
ing an attack of chorea, the child's disposition changes, he becomes ir- 
ritable, cannot concentrate his mind, memory is affected and halluci- 
nations may occur. The reflexes do not usually differ from the normal. 
Maniacal chorea is most serious, and often proves fatal, although re- 
cover}^ may occur. This form occurs most frequently in pregnant women. 
Speech is greatly affected and insomnia, fever and maniacal delirium de- 
velop. The duration is from six to ten weeks, in the average case. 
Mild cases may recover in a month or less, others last six or more months. 
There is a tendency of chorea to recur; rheumatism seems to favor this 
tendenc3% In children lecovery is the rule. 

Diagnosis. — In the majority of cases chorea is easily diagnosed. 
The symptoms are generally very characteristic. In a few cases of hys- 
teria there may be difficulty of diagnosis, but history and rhythmical 
movements wiU usually differentiate. In hereditary ataxia the slow, 
irregular movements, the scolioses, scanning speech, talipes and the ex- 
istence of other cases in the family, will differentiate this from chorea. 
Cerebral sclerosis usually occurs in infancy; impaired mentality, ex- 
aggerated reflexes, rigidity and chronic course of the disease, are points 
which render the diagnosis easy. 

Treatment. — Nearly all cases can be cured.^ The predisposing 
causes of chorea, osteopathically, are usually found to be subluxations 
of the vertebrae or ribs at any point, but particularly in the cervical verte- 
brae. Chorea is one of the diseases of the nervous system, in which con- 
stant morbid changes are not found upon the post-mortem examina- 
tion. Possibly the reason is because the lesions causing the diseased 
state are not deeply seated enough to primarily affect motor centers: 
but are lesions of the spinal column and ribs, affecting simply the nerve 
1. See A. O. A. Case Reports, Series II., III., IV., V. 



The Practice of Osteopathy 727 

fibers reflexly, as they pass through the intervertebral foramina. There 
will be found well marked lesions, and upon their correction the osteopath 
finds complete recovery largely depends. 

The muscle, or group of muscles, involved, will give a direct clue 
as to where the lesion will probably be found. In nearly all cases, it is 
in the spinal region of innervation to the affected muscles. Other cases 
may be due to cerebral lesions, as well as to intestinal and uterine dis- 
turbances. Search should be made for possible reflex irritation, such as 
intestinal parasites, adherent prepuce, eye strain, nasal abnormalities, 
etc. 

All cases should be taken from school, carefully guarded from ex- 
citement, and placed under the most favorable hygienic conditions, 
with a certain amount of discipline as to self control. The more serious 
cases should be placed in bed, so that rest will be secured as well as di- 
minished liability to heart complications. 

The diet must be carefully watched and the bowels attended to 
regularly. A milk diet during the earlj^ stage is highlj^ recommended. 
Do everything possible to restore the general health. Mild gymnas- 
tics, in most cases, will be found of service. Amusement should be 
given the child, in the open air if possible. In severe cases where the 
skin is harsh and dry, the hot air bath, providing the strength is good, will 
give considerable relief from the intensity of the disease. A few cases of 
acute chorea run into a chronic form, but the latter, as a rule, yields to 
osteopathic treatment. 

Choreiform Affections 

Myoclonia is a sudden contraction of a few muscle fibers, a single 
muscle or of a group of muscles. A neurotic tendency, infections and 
toxic conditions are factors. Occasionally epilepsy may be associated 
with it. Osteopathically there can be but little doubt that the innerva- 
tion to the muscles involved is interfered with. 

The lower extremities are usually first affected and it may be sudden 
or gradual in appearance. It is progressive and slowly involves the 
arms and, rarely, the face. Usually the spasms cease during sleep. 

Prognosis is rather favorable. Examination should show the 
cause of the nerve interference and its correction bring relief. 

Dubini's disease is probably associated with certain diseases of 
the c(jrd and bi'uin and is characterized by sudden, sharp pains in the 
head, neck and lumbar muscles, extending to the lower extremities in 
the form of a short, sharp spasm, usually at regular intervals. Later 



728 The Practice of Osteopathy 

there may be symptoms of hemiplegia. The disease is apt to progress 
and death maj^ occur during a convulsion. 

Habit spasm usually results from overstudy and nerve exhaustion 
with impairment of general health, and is incident to early life. The 
child is usually a neurotic. The symptoms are twitching of the mouth 
and eyelids, grimaces and jerking of the shoulders. Treatment for the 
general condition, with correction of any spinal lesions, will generally give 
relief. 

General tic resembles habit spasms closely. In some casas the pa- 
tient is apparentlj^ healthy, while in others there is some brain disorder. 
There are coordinate spasmodic movements of the head, face and upper 
trunk, swallowing and abnormal vocal sounds. The movements are 
^■apid and frequently repeated. Prognosis is uncertain and will depend 
largely on general conditions. In convulsive tic there is usually a 
repetition of certain words or sounds with a convulsive twitching or 
movement of certain muscles. 

Infantile Convulsions 

(ECLAMPSU) 

Infantile convulsions may be due to various causes. A neurotic 
inheritance is an important predisposing factor. They may precede the 
development of many diseases of the nervous system, and also occur as 
the result of peripheral irritation. Dentition in association with rickets, 
and intestinal parasites are common causes. They may be the early 
symptoms of acute, infectious diseases. Scarlet fever, measles, pneu- 
monia and smallpox are very frequently preceded by convulsions. They 
may be due to debility, resulting from gastro-intestinal disorders. Mal- 
nutrition is a predisposing cause. Disease of the bones, especially rick- 
ets, may be associated with convulsions. Lesions of the brain are other 
causes. A protracted instrumental delivery may cause a hemorrhage of 
the meninges. 

Symptoms.— In severe cases the fit may be identical with epilepsy. 
It is more often not so complete as true epilepsy. Convulsions vary 
considerably, but there will be no difficulty in diagnosis. It may come 
on suddenly, or be preced3d by restlessness, twitching, sometimes grind- 
ing of the teeth and fever. The spasms may be either of a tonic or clonic 
type preceded by a cry and loss of consciousness. The attack may be 
single, but the fits may follow each other with great rapidity and termi- 
nate fatally. It is rare for the child to die during a convulsion. Ex- 
haustion and asphyxiation may cause a fatal termination. As in epi- 



The Practice of Osteopathy 729 

lepsy the temperature often rises during the fit. A transient paresis 
sometimes follows, if the convulsions have been chiefly limited to one 
side. 

Diagnosis. — The diagnosis is generally easy. The attack is usually 
due to the ingestion of some indigestible food or to some peripheral irrita- 
tion, or an acute disease. Convulsions, appearing immediately after 
birth or injury, are probably due to meningeal hemorrhages or serious 
injuries to the cortex; although a few of these cases will present grave 
lesions of the cervical vertebrae, probably often due to protracted instru- 
mental delivery. Infantile convulsions usually occur between the fifth 
and twentieth months. Convulsions occurring after the second year 
are more likely to be true epilepsy. The prognosis depends almost 
wholly upon the cause, severity and duration. 

Treatment. — The first step in the treatment is to determine the 
cause if possible. Treatment in the region of the sixth and seventh dor- 
sals will often give relief; thorough work along the lumbar region and the 
sacrum will many times be sufficient, if the convulsion is due to intestinal 
disorder. C. M. Proctor reports that in male infants he has relieved 
convulsions quickly, in several cases, by pushing back the foreskin and 
has always found, in such cases, either a phimosis or an adherent pre- 
puce. In female infants it might be well to examine the clitoris. Dila- 
tation of the rectal sphincter may be of aid. It may be necessary to 
vomit the patient, when it is due to undigested food in the stomach; 
and in some cases an enema should be used, when the irritation is in the 
intestines. In a few cases, when the convulsions are due to dentition, a 
lancet applied to the gums will be all that is required. A thorough treat- 
ment to the cervical region, to control the circulation, should always be 
given; at the same time apply ice to the head. The patient should be 
put in a bath of 95 to 98 degrees F., should the preceding treatment not 
have the desired effect, or, better still, use the bath at once and treat 
at the same time. 

Owing to the neurotic tendency and the ofttimes trivial causes that 
precipitate an attack everything possible should be done to build up the 
general condition — adjustment of all lesions, regulated diet and dis- 
ciplined haljits. 

Epilepsy 

Definition. — A chronic affection of the nervous system, charac- 
terized by attacks of unconsciousness, which are usually accompanied 
by general convulsions. When there is merely a momentary loss of 



730 The Practice of Osteopathy 

consciousness it is called petit mal. Loss of consciousness with convul- 
sions is called grand mal. When the convulsion is localized, with or 
without loss of consciousness, it is called Jacksonian epilepsy. Cer- 
tain cases of temporary loss of consciousness are termed psycliic epilepsy. 

Etiology. — Epilepsy usually begins before puberty, and compara- 
tively seldom after the twenty-fifth year. Males suffer somewhat more 
frequently than females. Heredity predisposes to the disease to some 
extent, but probably not so greatly as many writers would claim. Neu- 
roses, as insanity and hysteria, and intermarriage of relatives, are im- 
portant elements to consider. When epilepsy is inherited, it is almost 
always due to some morbid state of the nervous system. Other predis- 
positions to the disease may be caused from defective general develop- 
ment of the brain, from impairment of the general health, and from an 
exhausted nervous system. 

Many exciting causes may l^e found: mental emotion, fright, 
excitement and anxiety; blows and injuries to the head; infectious dis- 
eases; syphiHs; alcoholism; masturbation; ocular and aural irritation; 
disturbed and delayed menstruation. Epilepsy may be excited by re- 
flex convulsions from intestinal worms, gastric irritation, etc. Also 
thickening of the membranes of the brain, pressure from a tumor at the 
periphery, uterine diseases and many other sources of irritation may be 
found, that are the exciting causes of epilepsy. 

Important exciting causes of epilepsy are, undoubtedly in many 
cases, due to lesions of the vertebrae and ribs especially the vertebrae of 
the cervical region, although in some cases the lesion is in the lower 
splanchnic region or in the ribs (chiefly from the fourth to the eighth) . 
These lesions to the spinal tissues disturb the nutrition to the vasomotor 
nerves. If the real seat of the disease is in the cerebral cortex and the 
medulla, the cervical lesion, and in fact other lesions, could readily affect 
the nerve force and circulation to and from these regions. The verte- 
bral artery circulation, where a cervical lesion exists, may be involved 
and affect the brain. In cases where lesions of the vertebrae and ribs 
exist in the upper and middle dorsal region, the vasomotor innervation 
to the brain may be involved, for in this region the vasomotor nerves to 
the cranium, etc., pass from the cord into the sympathetics. Birth 
injuries may affect the brain tissue, through cervical lesions, hemorrhages 
and asphyxiation. 

ConkHn attaches considerable importance to stasis of the sigmoid 
and ascending colon. Lesions involving this region may result in toxins 
entering the blood and affecting nervous tissue. 



The PRA.CTICE of Osteopathy 731 

To illuairate a specific exciting lesion, the following is interesting. 
The case was one of epilepsy that was evidently caused by a dislocated 
right fifth rib. By producing an irritation in the region of this rib, so 
that the lesion was increased, the patient could be made to immediately 
suffer from an attack of epilepsy. By resetting the rib, at once the 
sufferer would be entirely relieved. The case was cured after three 
months' treatment, the chief work being to keep the rib in place. Rarely 
a subdislocated innominate bone, or some lesion remote from the brain, 
is located and found to be causing epilepsy. Important lesions in most 
cases will be readily located in the cervical region. Booth reports: 
"I have records of seven fairly defined cases of epilepsy — such as have 
been so pronounced by M. D.'s. I find in all of them marked lesions 
in the upper cervical and in most of the cases the occiput is posterior 
upon the atlas or twisted. In all cases there was a thickening of the 
soft tissues, especially in the upper cervical. The lower cervical was also 
much involved but not so noticeably. All of the cases also presented 
marked disturbances in the upper dorsal; most were decidedly anterior, 
and one very posterior. One was almost a confirmed drunkard; not- 
withstanding the fact, he recovered to such an extent that he went to 
work, and I understand has been holding his position for more than three 
years. He had had to give up his work entirely. One was a hopeless 
case in every particular and did not seem to receive any benefit from the 
treatment. I think it was entirel}^ beyond help from any source. The 
others responded very well and the results were definite and decided. 
The length of treatment in successful cases ranges from about Rve weeks 
to a little over a year. But those that were treated the greater length of 
time were not treated continuously." 

After one convulsion has occurred, >' chers readily occur, owing 
to the proneness to changes in the nerve centers. Very little is known as 
to the pathology of this disease. Convulsions may be caused from irrita- 
tion of both the cortex cerebri and the medulla oblongata. From a 
study of the character of the aurse, one is led to believe that there is a 
disturbance, in most cases, in the centers of the cerebral cortex; and that 
the lesions so generally found along the spinal cohnnn are the true ex- 
citing causes of the disease. Perhaps in a few cases the irritation may 
be to the medulla reflexly. The lesions found on osteopathic examina- 
tion may act reflexly, as has been stated, upon the centers in the brain 
and excite them; or the circulation is deranged, and consequently the 
nutrition to the brain and meninges, by vasomotor control and the ver- 
tebral vessels, is impaired. 



732 The Practice of Osteopathy 

The splanchnic area and the cervical region should always receive 
special attention. This in conjunction with all possible reflex sources, 
and, not least, the general health, restoring a stable nervous sj^stem if 
possible, are of greatest importance. 

As a rule, pathological lesions are not found. To the naked eye the 
appearance of the nerve centers is largely that of healthy organs. The 
changes revealed by the microscope are most probably those of sec- 
ondary origin. Recent experiments seem to show that the motor zone 
of the cortex is affected. 

Symptoms. — These will be considered under the three varieties, 
known as grand mal, petit mal and Jacksonian. Grand maS. — In most 
cases the seizure is preceded by a pronounced sensation known as the 
aura. This differs greatly in various individuals. It may begin in a 
finger or toe and rise until it involves the head, when the patient screams 
and falls to the floor unconscious. In other cases the sensation may start 
from other parts of the body, as the epigastric region, where it maj^ 
simply be a sHght discomfort; or other sensations may be felt, as that 
of a ball rising from the stomach. The aura may start from any part 
of the body as a numbness, tingling, chilliness, etc., and may, also, be 
manifested through the optic, olfactory, auditory and gustatory nerves, 
l)y flashes, smells, sounds and tastes. ''Intellectual aurae" may also 
be manifested. Some form of aura is met with in nearly one-half the 
cases of epilepsy. Others lose consciousness so early that the patient is 
not aware of the onset. In cases not attacked suddenly and not pre- 
ceded by an aura, a prolonged prodrome may be present for several hours 
or a day. The patient may feel irritable, dizzj' or dispirited. Or he may 
be quiet and calmly await the attack. In a few cases certain move- 
ments may precede an attack, as running rapidly forward in a circle, or 
standing on the toes and rotating rapidly. The attack proper is sud- 
den. The patient falls with a peculiar cry. The convulsion or fit 
may be divided into three stages, that of tonic spasm, of clonic spasm 
and of coma. 

The tonic spasm succeeds the epileptic cry; there are loss of con- 
sciousness, pallor of the face and the contraction of pupils. The body 
assumes a position of tetanic rigidity, the head is retracted and rotated, 
and the spine curved, owing to an unequal affection of the muscles of the 
two sides. The jaws are fixed, the arms are flexed at the elbow, the hands 
at the wrist, and the fingers are clinched. The legs and feet are extended. 
The muscles of the chest are involved and respiration is suspended. 
This stage lasts a few seconds. The clonic spasm follows the tonic 



The Practice of Osteopathy 733 

spasm. The muscular contractions become intermittent. From slight 
vibratory motions, the intermittent muscular contraction becomes gen- 
eral. The arms and legs are thrown about violently, the muscles of the 
face are distorted, the eyes rolled, and the lips open and close. The 
muscles of the jaw contract violently and the tongue is apt to be bitten. 
The pupils are dilated, the face cyanosed (though at first the face is pale 
and pupils contracted) and blood streaked, frothy saliva pours from the 
mouth. The feces and urine may be discharged involuntarily. The 
temperatm-e rises about one degree F. This stage lasts about one or 
two minutes. The period of coma may last from a few minutes to 
several hours. Usually if left alone, the patient will awaken after a few 
hours. In a few cases mental confusion foll,ows the waking. During 
the stage of coma, the face is congested but not cyanotic. The muscles 
are relaxed and the breathing is noisy. Epileptic attacks during sleep, 
nocturnal epilepsy, are not rare. This may continue for some time 
without the patient being aware of it. 

Petit Mal.^ — In this variety of epilepsy, convulsions are absent. 
The seizure consists of momentary unconsciousness with fixed, staring 
eyes, dilated pupils and rarely any twitching of the muscles. After the 
attack the patient resumes his work. There may be attacks of vertigo, 
without unconsciousness, and the patient may fall. In a few instance 
there may be aurse of various kinds. Petit mal may be a forerunner of 
grand mal or the two may alternate. Between grand and petit mal 
there are many gi'ades of epilepsy varjdng in severity. 

Jacksonian Epilepsy. — The affection is always s^miptomatic of 
lesion in the motor area of the cortex. The lesion is quite apt to be a 
tumor, though various injuries, inflammation, sclerosis, softening, hemor- 
rhage or an abscess may be the cause. Consciousness is retained and 
the convulsions are limited in extent. Tonic and clonic spasms of the 
same character as in general epilepsy occur. A slight numbness, ting- 
ling, or twitching may precede the attack. 

The severity of epilepsy varies extremely. The seizure may occur 
but once a year or it may occur several times in a day. In many cases 
a marked periodicity is observed. The mental functions are not, as a 
rule, injured, but when the seizures are frequent, the health fails and the 
mental capacity is reduced. Many sufferers from epilepsy are subjects 
of chronic gastric catarrh, and have at the same time an inordinate appe- 
tite. Quite frequently a fit may follow inordinate eating. 

When there is a series of convulsions, which follow one another 
in rapid succession and which arc associated with high fever, the term 



734 The Practice of Osteopathy 

"status epilepticus" is applied. The most common form of epi- 
lepsy is the major form. About two-thirds of all attacks occur be- 
tween eight a. m. and eight p. m. 

Diagnosis. — Uremic convulsion closely resembles an epileptic 
convulsion. When the history of the case, analysis of the urine, in- 
creased temperature and the general health of the patient are all closely 
observed, error should be avoided. In reflex convulsions of cliildren, 
a careful search, and if necessary waiting a short time, will readily de- 
termine the source of the attack. When nocturnal convulsions take 
place without the knowledge of the patient the attack is epileptic. In 
hysterical convulsions the patient rarely loses consciousness. They 
rareh^ hurt themselves, never bite the tongue, the temperature is normal, 
opisthotonos does not occur, and the duration is usually longer. In 
Jacksonian epilepsy, the attack is hmited to some portion of the body, 
or it may gradually extend into a general convulsion. Care should be 
taken to recognize petit mal. 

Prognosis.^ — Records show that many cases have been cured and 
a much larger number have been benefited. 

Treatment. — Osteopathic treatment has been especially success- 
ful in epilepsy, as compared with other treatment. Although the os- 
teopaths do not claim a cure in every case, by any means, still about 
four out of every ten have been cured, while one-half of the remaining 
have been greatly helped in regard to the lessening of the severity of 
the attack, and in rendering the attacks less frequent. Conklin through 
his special treatment of fasting, dieting, enemata, spinal adjustment, 
and particular attention to the large bowel, especially cecum and colon, 
has increased this percentage. This is based on several hundred cases. 

Important lesions are usually found in the cervical region, from the 
third to the seventh vertebra, though they may be as high as the atlas. 
These lesions may affect the l^rain in various waj^s; probably in the man- 
ner described under the etiology. Lesions are also found in the dorsal 
vertebrae and when occurring below the cervical region, the lesions are 
generally found in the upper and middle dorsal regions, though they 
may be located at any point along the spinal column. 

The treatment is according to the rule that applies to all osteo- 
pathic work: an individual correction of the lesions presented in the 
case at hand. If any general movement or treatment might be given, 
it would be strong traction of the head to stretch the cervical vertebrae, 
or rather to separate them, so that the circulation to the brain may be 

1. See A. O. A. Case Reports, Series I., III., V. 



The Practice of Osteopathy 735 

equalized. Another general measure is to hyperextend the neck with 
fulcrum at juncture of atlas and occiput, thus releasing the upper anterior 
tissues that may impede cerebral cii'culation. 

If the lesions in such cases are in the cervical vertebra, probably 
they affect the cervical sympathetics. A careful search for a source 
of excitation must be made throughout the entii'e body. An irritation 
of the intestinal tract may be the exciting cause; or some irritation of 
the genito-urinary tract may be found, as phimosis, masturbation, etc., 
so that it is very necessary that gi'eat care be taken in the examination. 
Subjects of masturbation usually present lesions along the genito-urinary 
center in the spine. All possible reflex irritations should be eradicated. 

Proper hygienic measures should be added. Pay particular at- 
tention to the bowels. Place the patient in the knee-chest position and 
thoroughly raise the cecum and ascending colon in order to improve 
circulation and promote elimination. Baths are important, and plenty 
of fresh air and out-door exercise are of much significance. The paT 
tient's mind should be occupied. The question of food is an important 
one; general diet — carefully regulated as to the amount given- — should 
be prescribed. A vegetable diet is usually best. Reduction of salt 
seems to have a good effect. The patient must not be allowed to eat 
too much at a time, nor too often. If the bromides are being used, they 
should be withdrawn gradually. 

In most cases of true epilepsy a continued treatment of several 
months is necessary. Unless the patient can follow out ths treatment 
for several months, or even years, in a number of cases it will be entirely 
useless to take the treatment; although if the lesion present is very ap- 
parent, and the patient is enjoying fair health otherwise, and has not been 
affected long, a treatment for a few months, or even, weeks, might be 
all that is necessary. 

Surgical interference may be indicated in Jacksonian epilepsy. 
Trephining has been practiced successfully in a number of cases and 
the risk from operation with modern surgery is so reduced that one is 
fre(|Uontly justified in advising an operation. 

During an attack, a special treatment cannot be given to lessen 
the severity of the fit in all cases; in fact, most patients prefer not to have 
the seizure shortened as the after effects are more disagreeable. In some 
cases, at the beginning of the seizure, exerting a firm pressure upon the 
sub-occipital will quiet the patient. This treatment probably controls 
the circulation of the brain, by way of the superior cervical ganglion. 
In cases where the exciting factor seems to be in the intestines, and the 



736 The Practice of Osteopathy 

peristaltic action of the bowels is reversed, causing a reversion of the 
nerv5 current of the vagi, a rapid, firm kneading over the abdomen, so 
as to establish normal peristalsis, will suffice to prevent an attack, if 
one is notified of its approach. In some cases a rapid, thorough stimu- 
lation of the solar plexus will lessen an attack. Possiblj^ it reduces the 
blood pressure in the brain, by bringing blood to the splanchnic region. 
In all cases during the convulsion the patient should be carefully 
protected from injuring himself. A towel should be twisted and placed 
in the mouth, so that the tongue cannot be bitten. Do not place small 
articles as corks, etc., between the teeth, as they are liable to enter the 
pharynx and cause suffocation. The patient should be watched to pro- 
tect him from any injury; otherwise the attack should usually be allowed 
to spend itself. 

Migraine 

(Sick Headache) 

Migraine or sick headache is a neurosis, characterized by a par- 
oxysmal pain in the head, usuallj^ unilateral and periodical, with nausea, 
frequentlj^ vomiting, and disorders of vision. 

Osteopatliic Etiology. — The disease usually begins in the first 
half of life, rarely earher than puberty and is slightly more frequent in 
females. Some weakened or depressed condition of the nervous sys- 
tem, due to lesions of the upper cervical vertebrae, lesions of the inferior 
maxilla, anxiety, overfatigue, anemia, digestive derangements, eye- 
strain and menstrual disorders, is generally the cause. The hereditary 
factor is very important. This is frequently associated with derange- 
ment of the large bowel, especialty cecum and ascending colon, result- 
ing in toxemia. 

It is supposed bj' some to be a vasomotor disturbance, because 
there are symptoms, as pallor and flushing of the skin, which show an 
involvement of the sympathetic system. It is possible a spasm of cere- 
bral arteries, followed by vascular dilatation, takes place. The seat of 
the pain is beheved to be in the meninges of the brain. Possibly in many 
cases where the atlas is found involved and causing the affection, some 
meningeal fiber of the fifth nerve is impinged by the lesion. Caries of 
the teeth and nasal troubles are causes of the disease in children. 

Symptoms. — A paroxysmal headache is the principal feature of 
migraine. The attack may occur without warning, although there are 
usually malaise, restlessness and a disturbed vision preceding the head- 
ache. The prodromal symptoms vary to a great extent. Other pro- 



The Pkactice of Osteopathy 737 

dromal symptoms besides those given, may be vertigo, spots before the 
eyes, tinnitus, chilHness, etc. The pain is of a sharp and stabbing nature 
and is oftentimes hmited to the temporal region of one side. Others 
describe the pain as of a binding or of a boring nature. It is continuous. 
It may be in the occiput instead of in the side of the head. 

Hyperesthesia of the surface is noticed, but the tender points 
of neuralgia of the fifth nerve are absent. The patient is sensitive to 
light and noise. Flashes of light occasionally attend the pain in the head. 
Hemianopia is not infrequent. The temporal artery may be contracted, 
the face pale and the pupil large. In others the eye is dilated, the face 
flushed and the pupil small. Nausea and vomiting are frequent, with loss 
of appetite. In some cases where the stomach is full, vomiting the con- 
tents win relieve the attack. Should the stomach be empty, vomiting 
of mucus may occur, and is later followed by vomiting of bile. Tender- 
ness is commonly found about the region of the occipital and upper cer- 
vical muscles. Attacks rarely occur oftener than once in ten or fifteen 
days. During the intervals the patient may be quite well. The dura- 
tion is anywhere from a few hours to several days. 

Diagnosis. — The sensory symptoms, the paroxysmal character, 
the severity and definite course, usually readily distinguish migraine. 
Growths of the brain may be the cause of symptoms closely simulating 
migraine. In such cases an ophthalmoscopic examination may reveal 
a choked disc. 

Prognosis. — Is usually favorable when the attacks are light and 
of short duration. Cases of long standing and of great severity are not 
so easily cured, although in most instances great relief can be given the 
patient. There are very few cases in which the severity and frequency 
of attacks cannot at least be lessened. Oftentimes attacks of migraine 
cease after middle life. 

Treatment. — The atlas or one of the upper cervical vertebrae 
is almost invariably subluxated. This is not always the direct cause of 
migraine, but it is an important factor in the causation. During the 
attack many cases can be completely, or at least partially relieved, by 
a careful treatment in the upper cervical region. But there are some 
cases where treatment of the cervical region is entirely unsuccessful, and, 
in fact, aggravates the attack. The details of treatment vary in every 
case. If any defects in general health or any error in the mode of living 
can be found, these of course must receive first attention. Rest, diet 
(a vegetable diet is best) and regularity of meals are usually to be spe- 
cially considered. Anything that is known to induce an attack must be 



738 The Peactice of Osteopathy 

carefully avoided. In some patients the attacks cease so long as they 
remain free from mental work, but as soon as they return to their studies 
the paroxysms occur. 

Every case should be thoroughly examined before a course of treat- 
ment is laid down. Causal conditions can generally be found, and the 
correction of such usually results in a cure, or at least in great relief. 
Errors in diet; digestive disturbances, as a disordered biliary tract; dis- 
orders of the pelvic organs; eye-strain; nasal disorders; mental and phys- 
ical fatigue, and affections of the nose may induce attacks. 

A beneficial treatment for many, aside from adjusting the spinal le- 
sions, especially the cervical and usually a rigid splanchnic area, is to place 
the patient in the knee-chest position and thoroughly raise the bowels of 
the right side beginning in the right iliac, loosening possible adhesions, etc. 

The earlier the treatment, the more likelihood of a cure. Cases of 
long standing are generally harder to cure. Preceding a paroxysm, re- 
lief can usually be given, but after the paroxysm has reached its height 
it is harder to give relief. The patient should rest in a quiet room which 
is darkened and well ventilated. Besides the indicated osteopathic 
treatment (generally a cervical one), hot applications to the nape of the 
neck and keeping the extremities warm are helpful. The nerves in- 
volved are the vasomotor, occipital, frontal and temporal. A free evac- 
uation of the bowels will relieve a few cases, while washing out the stom- 
ach will help others. Hot fomentations over the splanchnics for thirty 
minutes may be beneficial. During the intervals, valuable adjuncts 
will be found in the use of systematic exercises and frequent bathing. 
Do not fail to have the eyes examined. 

Occupation Neurosis 

These are a group of maladies of the nervous system, due to ex- 
cessive use of certain muscles in some oft repeated act, and character- 
ized by spasm of the muscles concerned. There are several varieties, as 
writers' cramp, telegraphers' cramp, piano players' cramp, viohn play- 
ers' cramp, typewriters' cramp, etc. 

Professional spasms, that involve muscles of the shoulder girdle, are 
not rare among osteopathic practitioners, due to prolonged faulty meth- 
ods of technique. 

Osteopathic Etiology. — A nervous temperament predisposes to 
the development of the affection. Previous injuries and strains of the 
involved parts are important factors. Faulty methods of writing, and 
in the other disorders, strained or cramped positions of the affected tis- 



The Practice of Osteopathy 739 

sues, predispose to attacks. Slight lesions of the bones, joints, liga- 
ments and muscles are commonly found, involving the motor and sen- 
sory nerves of the immediate locahty. The majority of all cases occur 
between twenty and fifty years of age. 

Distinctive pathological changes have not been found. Each case 
has particular lesions of its own. The details of the case are charac- 
teristic of the one case only. The affection is often primarily a spinal 
one, due to deranged action of the spinal centers concerned in the var- 
ious acts; though, no doubt, excessive use of a group of muscles may re- 
sult in contractions, spasms, contractures and nutritional changes, that 
in turn will establish definite osteopathic lesions. This is an illustra- 
tion of a "vicious circle. " 

Symptoms. — Symptoms of the various varieties of professional 
neuroses develop slowly and gradually. A cramp or spasm affecting 
the used member is an early symptom. Tremor, weakness, stiffness, 
fatigue and heaviness of the affected part are present most of the time. 
In severe cases neuritis may develop, and a glossiness of the skin be pres- 
ent. Associated with the inabihty to perform the usual work, may be 
mental worry and depression. 

Diagnosis. — The history of the case and the hmitation of the dis- 
ease to one member, usually make the diagnosis easy: Cerebrospinal 
diseases, as hemiplegia; early tabes, affecting the arms; and progressive 
muscular atrophy, have to be carefully excluded. 

Prognosis. — As a rule is favorable. Osteopathic treatment, in 
the majority of cases treated, has resulted in recovery. 

Treatment. — Rest of the part, mental quiet and attention to the 
nutrition of the patient, are the first essential considerations. A change 
of occupation may be necessary if excessive use of parts and faulty meth- 
ods can not be coiTected. The treatment consists of a correction of the 
parts iiTitating or disturbing the spinal centers or nerves affected. The 
ulnar, radial and median nerves all innervate muscles employed in writ- 
ing. Lesions of the cord affecting these nerves may be found from the 
fifth cervical to the sixth dorsal. In a few cases lesions occur as high as 
the atlas. When the radial and median nerves are involved the lesions 
are principally found in the upper dorsal vertebrse. When the ulnar 
nerve is involved the lesions are usually slightly lower. The lesions may 
affect the fibers of these nerves directly (mechanically), but more prob- 
ably the vasomotor nerves are involved, as in this region the vasomotor 
fibers to the arm pass from the cord to the sympathetic fibers. The 
brachial plexus originates higher than the upper middle dorsal region, 



740 The Pil\ctice of Osteopathy 

still some of its nerves are frequently affected in the dorsal region by os- 
teopathic lesions, for removal of the same relieves the disorder. 

Other lesions affecting the arms are oftentimes found in the ribs on 
the side involved. Any of the first five ribs may become deranged and 
affect the innervation of the arm. The clavicle in a few cases may be 
abnormaUy low. A bursitis may be present. Occasionally shght sub- 
dislocations of the shoulder joint (especially anterior) and elbow joint 
are found. Gymnastic exercises of the arm and hand, coupled with a 
general treatment of the shoulder, arm and hand, are beneficial. Hy- 
drotherapy, massage and friction of the involved member are useful. 
In severe cases ''breaking up" fibrotic tissue, and muscle training fre- 
quently secures good results. 

Hysteria 

Oppenheim defines hysteria as ''a psychosis, which does not express 
itself by disorders of the intellect, but in defects of character and emo- 
tional disturbances, whose real nature is hidden under an almost unlim- 
ited and varied number of physical symptoms of disease. " 

The affection is about equally divided between the two^ sexes. A 
neurotic tendency, often inherited, is an important underlying factor. 
This condition, when associated with lack of mental disciphne, is very 
apt to lead to the mental depression and outbreaks of hysteria. A large 
number of cases are between the ages of puberty and twenty-five. After 
forty-five the disorder is infrequent. 

White, Osier's System of Medicine, says: "The significance ot 
Freud's theory is the tracing of every case to sexual traumata during 
childhood. Sexual experiences differ, however, from ordinary experi- 
ences—the latter have a tendency to fade out, while the idea of the former 
grows with increasing sexual matm-ity. There results a disproportionate 
capacity for increased reaction which takes place in the subconscious. 
This is the cause of the mischief." A distinction is made between the 
sexual and the sensual. 

Anders points out that lack of proper mental development, unproper 
hygienic surroundings and chronic toxemia are causes. 

The direct causes of hysteria may be many, and include physical 
and mental influence, or both. Traumatism of various regions of the 
body, but especially of the spinal column, may excite hysteria. Some 
slight lesion of the vertebra or rib may be all that is discoverable. A 
correction of the same is occasionally all that is necessary to remove the 
direct cause; still there is usually considerable disturbance of the spmal 



The Practice of Osteopathy 741 

tissues, especially slight curvatures and muscular contractions. Pro- 
longed emotional excitement, overwork, defective education and many 
moral and mental influences are potent and frequent causes. Mas- 
turbation or an adherent prepuce occasionally is the cause of the affec- 
tion in boys, or any excitation that produces exhaustion. Distiu-bances 
of the sexual system in both sexes are responsible for many cases. The 
menstrual period and the menopause are frequent periods for the mani- 
festation of the disease. The disease often affects prostitutes. Dis- 
turbances of the digestive, nervous and circulatory systems, and general 
diseases of an exhaustive kind are exciting causes of hysteria. Dr. Still 
said that occasionally the colon is prolapsed and crowded down upon the 
pelvic organs. Hazzard^ is of the opinion that "a majority of the cases 
show a depression of all the ribs, narrowing the thorax and often causing 
enteroptosis. " 

Symptoms. — The symptoms may be extremely varied, including 
any symptom of the many nervous diseases. The sensory symptoms 
are numerous. The most common is anesthesia, which may be found in 
certain parts of the body, usually one side (the left) of the body. Geo- 
metrical areas that bear no relation to the innervation is characteristic. 
The patient may not know of the sensory derangements until discovered 
by the physician. When there is anesthesia without other nervous 
symptoms, the case is commonly hysterical. The most marked symp- 
tom is analgesia, where the patient is insensible to painful impressions. 
A pin may be placed deeply into the flesh, and not be felt by the patient. 
The anesthesia may extend to the mucous surfaces, and even deeply 
down to the tissues of the joints. Organic and tendon reflexes are not 
changed. There may be other symptoms of disturbed sensation; as an 
absence of pressure, temperature and muscular sensation. 

Hyperesthesia may be present nearly as often as anesthesia. Hy- 
peresthetic areas may be found in various regions of the body, but es- 
pecially along the spinal column and in the ovarian region. The ''hys- 
terical spinal irritability" is of special interest to the osteopath. The 
spinal column may be affected as a whole, or in segments, or confined to 
a single vertebra. Especially when a spinal irritability is in segments, 
or confined to a single vertebra, are local derangements of the spinal 
column apt to be found. Correction or even pressure upon these areas 
will often relieve the patient. Severe pain over the heart may simulate 
angina pectoris. Globous hystericus is of quite common occurrence. 

Charcot refers to the ovarian hyperesthesia as follows: "It is 
1 . Practice of Osteopathy. 



742 The Practice of Osteopathy 

indicated by pain in the lower part of the abdomen, usually felt on one 
side, especially the left, but sometimes on both, and occupying the ex- 
treme limits of the hyperesthetic region. It may be extremely acute, 
the patient not tolerating the slightest touch; but in other cases pressure 
is necessary to bring it out. The ovary may be felt to be tumefied and 
enlarged. When the condition is unilateral, it may be accompanied 
with hemianesthesia, paresis, or contracture on the same side as the 
ovarialgia; if it is bilateral, these phemomena also become bilateral. 
Pressure upon the ovary brings out certain sensations which constitute 
the aura hysteria, but firm and systematic compression has frequently 
a decisive effect upon the hysterical convulsive attack, the intensity of 
which it can diminish, and even the cessation of which it may some- 
times determine, though it has no effect upon the permanent symptoms 
of hysteria. " 

The special senses may be disturbed, although these symptoms 
are usually transient. There may be blindness; narrowing of the field 
of vision, due to anesthesia of the periphery of the retina; loss of hearing; 
loss of smell or loss of taste. 

Motor disorders may be of different forms of paralysis, as hemi- 
plegia, paraplegia or monoplegia. In fact all forms of parlaysis may be 
found in hysterical patients. Osier says: "There is no type or form of 
organic paralysis which may not be simulated in hysteria. " The affected 
muscles do not atrophy. The paralysis is usually general, and contrac- 
tures are common. Local paralysis, as of the bladder, vocal cords and 
other parts of the body, commonly occur. 

Contractures and spasms may also occur. True epilepsy may 
even be simulated by hysterical spasms, but on careful observation the 
characteristic attack of epilepsy is found wanting. Firm pressure may 
increase the severity of an attack as well as bring it on. The spasms are 
of various parts of the body, as the diaphragm, bronchi, abdominal mus- 
cles, bladder, etc. 

Various disturbances of the viscera may occur. Of the digestive 
tracts, the appetite may be disturl^ed or depraved. Diarrhea or consti- 
pation may be present. Flatulency is a common sj^mptom. The re- 
spiratory tract ma}^ be another point of considerable disturbance in 
many cases. Dyspnea, aphonia, hiccough, cough, and exaggerated 
breathing, as when cold water is poured on one, are common manifesta- 
tions. Various cardiac vascular symptoms may be manifested, es- 
pecially a rapid heart. Various vasomotor derangements are common. 

Physical manifestations, as amnesia, lack of will power and an 



The Practice of Osteopathy 743 

excitable nature — easily moved to laughter or tears — are frequent. The 
moral tone may be lowered. Even delirium, catalepsy, ecstasy and 
trance, may be mentioned among the psychical phenomena. 

The hysterogenous zones are of more than passing interest to the 
osteopath. Tyson writes as follows, in regard to the hysterogenous zones : 
"These are hyperesthetic areas especially studied by Richet, on which 
persistent pressure will sometimes excite a hysterical attack. While 
the ovaries are favorite hysterogenous zones, the zones may be in any 
part of the body; as for example, the sides of the trunk. Such pressure 
may also cause an existing attack to subside. Hysterical spasms may 
also be locahzed or Umited to groups of muscles." Especially when 
zones along the spine and side of the trunk are located, the attack of 
hysteria may be completely relieved by correcting the locahzed deranged 
tissues. 

Convulsive seizures are not unconmaon and may follow various 
prodromal sj'mptoms. Some authors divide the symptoms of hysteria 
into convulsive and non-convulsive forms. 

These are part of the many manifestations that are presented by 
various hysterical patients, and it is readily seen that an osteopath has 
to be continually on his guard. 

Diagnosis. — The diagnosis is generally quite easy. The charac- 
teristic emotional symptoms, associated with any of the many other 
symptoms which have no organic lesion, are characteristic of the dis- 
ease. Care has to be taken, though, in some cases where symptoms are 
presented which have organic lesions. The history, the attack and 
neurotic temperament, will largely decide the nature of the affection. 
After the "outbreak" the patient often feels decidedly better. 

Prognosis. — Death may occur from exhaustion, but such a termina- 
tion is rare. Recovery is the rule, although the duration may be long. 
Recoveiy usually takes place rapidly, after the exciting cause has been 
determined and removed. 

Treatment. — First of all, the osteopath should have due apprecia- 
tion of the mental characteristics of the disease. Whatever is dominat- 
ing the patient mentally must be either changed or aboKshed. It is not 
always necessary to be harsh and severe with the patient; but one should 
be firm and unyielding. He can do a great deal by having complete ment- 
al control of the hysterical patient. 

A most careful examination should be made for an exciting cause, 
and when found it should be removed. This naturally constitutes a very 
important part of the treatment. A light general treatment is commonly 



744 The Practice of Osteopathy 

indicated. The general health, especially the bowels, should be care- 
fully attended to. The hygiene, exercise and amusement of the patient 
should receive due consideration. One has to gain the confidence of the 
patient, and then be firm but kind to him. Relative to diet Yeo^ says: 
"The diet should be simple, abundant, and supplied regularly, and at 
not too long intervals as is frequently the case in boarding schools. All 
strong stimulants are best avoided, and the hysterical should not in- 
dulge in strong tea or coffee, or exciting wines and liquors." 

The "rest cure" as introduced by Weir IViitchell, is applicable in 
some cases. This method consists of plenty of food, especially milk, 
absolute rest of the body and mind, massage and electricity with isola- 
tion of the patient from friends and sympathetic relatives. Doubtless 
a general osteopathic treatment would be much better than massage. 
Yeo says that to the appUcation of hypnotism and suggestion "we look 
with little sympathy and less confidence. " 

Dtu'ing the hysterical convulsions, the patient should be watched, 
but extreme measures should not be practiced. There is little danger of 
patients hurting themselves. Throwing cold water in the face, or a cold 
bath may produce the necessary mental shock. Pressure over the ovary 
as stated in hysterogenous zones, or some other zone of the body, or 
pressure upon a large blood-vessel, as a carotid, will oftentimes stop an 
attack. 

Neurasthenia 

"Closely aUied to, and in some cases ahnost inseparable from, hys- 
terical states are those morbid conditions to which, in modern times, has 
been applied the term neurasthenia. " (Yeo). Neurasthenia is a fatigue 
neurosis that is characterized by mental and physical irritability and 
inefficiency. Headache, backache, insomnia, and debility of the gastro- 
intestinal tract are common symptoms. 

The affection is often found in that class of people who are predis- 
posed to hysteria. The disease is more common among men than women, 
usually occurring after the twentieth year. The predisposition may be 
inherited or acquired. Church states that "debilitating conditions in 
the antecedents of neurasthenics," and "defective education that omits 
discipline and the cultivation of self control" are important predisposing 
causes. Many of the exciting causes that produce hysteria will cause 
neurasthenia. Various lesions along the spinal column, chiefly in the 
cervical and upper dorsal regions, include the predisposing causes of a 

1. Manual of Medical Treatment. 



The Practice of Osteopathy 745 

large majority of cases. This spinal irritation, taken in conjunction with 
overstrain of niind and body, or probably in many cases the spinal irrita- 
tion as the predisposing cause of the over strain, results in nervous ex- 
haustion. Particularly overwork, associated with care and anxiety, is 
an exciting cause of great significance. 

The neurasthenic patient is generally of a neurotic temperament. 
The affection may, also, result from various chronic diseases, toxic con- 
ditions, sexual excesses, alcohol and tobacco. Thompson^ believes that 
improper sexual hygiene and perversion or abuse of the marital relation 
are most important factors in the development of neiu^asthenia in both 
sexes, and a regulation of this is imperative for a cure. The symptoms 
are due, to a greater or less extent, upon spinal, cerebral, cardiac and 
gastric disturbances, but all of these conditions are usually dependent 
upon vertebral and rib lesions of the upper dorsal and cervical regions. 
Care should be taken whether the condition is secondary to organic 
lesions. The lesions in the vertebrae are generally shght lateral devia- 
tions, in the ribs upward displacements of the vertebral ends, followed 
by contraction of the deep muscles in the neighborhood of the lesions. 
A posterior condition of the atlas and a lateral lesion between the third 
and fourth dorsal are especially apt to be found. As to spinal areas most 
affected Stearns" says the predisposing irritations are located particularly 
in the first two cervical, the first two dorsal and the last two Imnbar 
vertebrse. 

These various lesions probably cause an impairment of nutrition in 
the nerve-centers of the cord and brain, or both. Definite morbid 
anatomical changes have not been found resulting from nervous de- 
bility or irritabihty. Still, it seems probable that certain changes in the 
nerve-cells may result from excessive functional activity. Traumatism 
is a prominent causative factor in both neurasthenia and hysteria. 
Railway and other injuries frequently produce osteopathic lesions that 
result in nervous disorders. That there is a demonstrable pathological 
basis resting in sympathetics and spinal nerves, there can be no doubt. 
Symptoms. — To enumerate the many symptoms of neurasthenia 
in detail is hardly necessary. The nervous debility may affect any or- 
gan of the body, owing to the exhaustion of the nervous energy, thus 
lessening the functional activity of that organ. 

^riic most noticealjle symptoms are various sensory disturbances 
and muscular weakness, dependent in part upon the spinal lesions. 

1. Cosmopolitan Osteopath, October, 1903. 

2. Journal of Osteopathy, January, 1904. 



746 The Practice of Osteopathy 

The patient generally feels weak and tii-ed. Headache, pains in the 
back and sacrum, tender points along the spine, and various sensations 
of numbness, tingling, etc., are felt. 

The mental faculties are oftentimes irritable and weak. An in- 
ability to concentrate the thoughts with depression, fear, vertigo, insom- 
nia, and many other mental symptoms, may be manifested. 

Palpitation, irregular action of the heart and pain over the pre- 
cordia may be present. Ocular distm-bances, particularly blurring of 
letters and narrowing of the visual field, visceral symptoms of many 
kinds, and vasomotor phenomena, as chilUness, flashes of heat and sweat- 
ing, are among the many symptoms of which the patient complains. 

Genito-urinary disorders in the male, and ovarian and uterine 
irritation and painful menstruation in the female, are occasionally symp- 
toms dreaded ])y the sufferer. Pohmria is frequent. 

The symptoms or signs of great importance to the osteopath in 
neurasthenia, as in manj^ other diseases, are the tender points along the 
spinal column. They give direct clues as to where the lesion may be 
found. 

Diagnosis. — Error in diagnosis can usually be prevented by a study 
of the history of the case and symptoms. Care must be taken in deter- 
mining between symptoms of organic diseases and the symptoms of a 
true nervous exhaustion. 

Prognosis. — Is abnost invariably good. Only in cases where there 
is a tendency to mental disorder should the prognosis be guarded. Much 
depends upon the thorough cooperation of the patient. It usually 
takes some time to perform a cure among the poorer class, as the require- 
ments demanded for a cure are oftentimes expensive. 

Treatment. — Naturally the treatment, exclusive of the manipula- 
tion to correct the various lesions found, is extremely varied, owing to 
the many exciting causes and sjnnptoms to contend with. 

As has been stated, the lesions are usually found in the upper spinal 
region; still lesions are occasionally located in the lower spinal region, 
especially in female sufferers, when the pelvic organs are disturbed. 
The many mental symptoms, as inabihty to concentrate the mind, in- 
somnia, vertigo, headache, etc., are best treated through the cervical 
region, with attention to the heart's action and the excretory organs. 
Careful attention should be paid to the deep posterior muscles between 
the atlas and occipital bones. 

Rest is very necessary. Changes of scene and occupation, atten- 
tion to the surroundings, careful dieting, hydrotherapeutic measures, 



The Practice of Osteopathy 747 

pleasant companions, relief from responsibility, bathing, etc., should 
receive careful attention and consideration by the osteopath. Set rules 
cannot be given. The details of treatment that should be adopted are 
dependent upon the individual case. Every well trained osteopath will 
be familiar with such measures. 

Careful attention must be given to the secretions, excretory organs 
and the circulation. A study of each case will bring out the various 
irregularities that may exist. 

When the nervous involvement is extensive, a "general treatment" 
may be given. Such a treatment would affect the entire nervous and 
muscular system, and tend to equalize disturbed nerve force. Bringing 
the muscular system into play and relaxing contracted muscles calls for 
more blood and nerve force, and consequently a nutritious diet. 

The "rest cure," as introduced by Weir Mitchell, may be employed 
to considerable advantage in many cases. Yeo says: "It is in certain 
cases of this disease that the 'rest cure,' devised by Weir Mitchell, has 
proved so remarkably successful. But there can be no sort of doubt that 
it has been apphed far too indiscriminately, and that for this, as indeed 
for any special method of treatment, a careful selection of suitable cases 
is needful. " The diet should consist principally of milk at first, followed 
in a few days by soft boiled eggs, boiled rice, lamb chops, graham bread, 
steAved fruits and butter, and a little later by roast beef, vegetables and 
light puddings. Porter's system of milk diet has proved effective in 
many cases. Tea, coffee and alcohol should be avoided. 

During the entire course of the treatment, care should be taken to 
correct any lesion that may bear directly upon the cervical sympathetic, 
the solar plexus and the hypogastric plexus, as they are the great reflex 
centers of the body. 



748 The Practice of Osteopathy 

DISEASES OF THE SPINAL CORD 

Acute Myelitis 

Acute myelitis is an acute inflammation, with softening of the 
substance of the cord, gi\dng rise to marked disturbances of motion, sen- 
sation and nutrition. When the whole thickness of a section of the cord 
is involved, the condition is termed transverse myelitis. When an 
extensive area is involved, it is termed diffuse myelitis. When the gray 
matter around the central canal is especially affected, it is termed cen- 
tral myelitis. 

Etiology. — There can be no doubt that osteopathic lesions are 
very potent predisposing factors. Osteopathic lesions of the spine, even 
of a muscular nature, readily disturb the cord circulation. It may 
follow repeated exposure to wet, cold or exertion; or be a sequel to the 
infectious diseases, as smallpox, typhoid fever, typhus, puerperal fever 
or measles. It may be due to traumatism or disease of the vertebrae, as 
caries or cancer. Syphilis is a frequent cause. 

Pathology. — To the untrained, naked eye, the cord may present 
little or no change. The nervous tissues are in various stages of degen- 
eration. On section the substance of the cord is red and soft, the Une 
of demarcation between the gray and white matter is lost or extremely 
indistinct, and minute hemorrhages are sometimes seen. In very acute 
cases, affecting the white and gray matter, after injury, when the mem- 
branes are cut, the substance of the cord may flow out as a reddish creamy 
fluid. 

The nerve fibers are much swollen and the axis cjdinders broken up. 
Blood discs, leucocytes, and numerous granular fatty cells may also be 
present. The blood-vessels are distended and dilated. There may be 
tliickening and hyaline degeneration of the vessel walls and hemorrhagic 
extravasation. 

Symptoms. — Acute Transverse Myelitis. — This is the type 
most frequently met with. The symptoms differ with the situation of the 
lesion, which is generalh^ in the dorsal cord. At the onset there may be 
pain; numbness and tingUng in the back, radiating into the Hmbs. There 
is usually moderate fever, malaise, chills, muscular pains, a coated tongue 
and constipation. Sjanptoms of motor paralysis soon develop, which 
may become more or less complete. Both motor and sensory symptoms 
vary to a marked degree, depending upon the pathologic involvement. 
The reflexes are lost at first. They may soon return and are exaggerated 



The Practice of Osteopathy 749 

below the lesion. Following this the muscles often become rigid and 
contracted. Unless the lesion is in the lumbar or cervical cord, reaction 
of degeneration or much wasting of the muscles, as a rule, does not occur. 
A girdle sensation frequently occurs at the level of the disease. At 
first there is retention of the urine and feces, later incontinence. Bed- 
sores soon develop; also drpng and hardening of the skin. The nails 
become thick and brittle. Death may occur from exhaustion, or heart or 
respiratory failure, but it is rare; segments of the cord may be com- 
pletely and permanently destroyed, causing persistent paraplegia. H. 
A. Greene'^ reports a case, due to injury, which was greatly benefited by 
treatment. 

Acute Diffuse Myelitis. — In the acute forms the course of the 
disease is rapid. The trophic disturbances are more marked than in 
the former type. This form is Kkely to follow exposure to cold, injuries, 
tumors, syphilis or one of the infectious diseases. There may be chills, 
fever, malaise, pain in the back and limbs, and occasionally convulsions. 
The reflexes are generally lost. The motor functions are rapidly lost. 
There is incontinence of urine and feces, rapid wasting of the muscles 
and bed-sores develop. The disease may prove fatal in from six to 
ten days. 

Diagnosis. — Landry's Disease. — In this the bladder and rectum 
are not affected. Trophic disturbances are absent. There is but shght 
loss of sensation, no reactions of degeneration and no girdle pains. 
Multiple Neuritis. — Both arms and legs involved, and slow onset. 
The bladder and rectum are rarely involved; the girdle pain is absent. 
Acute Poliomyelitis. — There are no sensory symptoms and the rec- 
tum and bladder are not affected. 

Prognosis. — In very acute cases death occurs in from three to ten 
days. Milder cases generally recover with some loss of motor power, 
although in a few cases treated by osteopathy recovery was complete, 
due probably to the case being seen early and thus degeneration pre- 
vented. 

Treatment. — Lesions of the vertebrae are usually readily found 
in cases of myelitis. Generally, deranged vertebrae are found in the 
upper dorsal region, and occasionally lesions are located in the lumlmr 
and cervical vertebrae. The treatment of myelitis is chiefly to correct these 
lesions, so that the normal circulation of the cord may be recstabhshed. 
One has to he very careful when treating the lesions not to cause ad- 
ditional injury to the cord. An inhibitory treatment to the muscles 

1. A. O. A. Case Reports, Series V. 



750 



The Practice of Osteopathy 



about the lesion may be all the treatment that can be given at first; never- 
theless, it aids natm'e just so much in overcoming the excessive irrita- 
tion of the cord tissues. Natm-e has the curative means, provided they 
may operate unobstructedly. In a few cases the ribs in the region of 
the spinal lesion will be found deranged and interfering with trophic 
fibers, blood-vessels and l>Tnph vessels of the cord. The patient should 
be kept in the prone posture at first. 

Warm baths and massage will be found of additional value. The 
bowels and bladder should receive special attention. An ice-bag to the 
spine may be beneficial. If there is anj^ danger of bed-sores, use alcohol 
to stimulate and harden the skin. Rest, hquid diet and good nursing are 
necessary. Later on careful exercising of the limbs will be beneficial. 

Chronic Myelitis. — This defines the conditions when the in- 
flammation is subacute with the paraplegia and other sjinptoms which 
then naturally appear, present, and also with the signs of both degenera- 
tion and repair. The sj^nptoms develop slowly as compared with the 
acute form. It should not be confused with atrophy, pach;>Tiieningitis or 
tumors of the cord. Treatment is practically the same as in acute 
form. Surgical measm^es may be indicated. Loudon^ reports a case 
due to injury which was greatly benefited. 

Poliomyelitis 

(Infantile Paralysis) 

Definition. — An acute infectious disease occurring most commonly 
in young children, characterized by paralysis, rapid wasting of certain 
muscles, and fever. It is an acute mj'ehtis that affects the anterior 
horns of the cord. There are no sensory symptoms. 

Etiology. — It usually occurs in children under ten years of age, 
and the majority of cases occur before the fourth year. It is more com- 
mon in summer than in winter. The infection seems to gain entrance 
through the nasal mucous membrane. Traumatism, exposure to cold 
and overexertion, are probably predisposing causes. It has occurred 
in severe epidemic form. 

Morbid Anatomy. — The disease is most frequently seen in either 
the limibar or cervical enlargement and is usually unilateral, though 
there is considerable variation in the extent of the lesions. In very 
early cases, the condition of acute hemorrhagic myelitis, with degenera- 
tion and rapid destruction of the large ganglion cells, has been found. 
In older lesions the anterior cornu in the affected region is atrophied and 

1. A. O. A. Case Reports, Series II. 



The Practice of Osteopathy 751 

there is destruction of the multipolar ganghon cells. The anterior nerve 
roots are atrophied, the muscles are wasted and undergo a fattj'" and 
sclerotic change. 

Symptoms. — The child may have a slight fever, malaise, muscu- 
lar twitching, headache, some rigidity of the neck, and sometimes vom- 
iting. This may last a day or several days or only a few hours, when 
paralysis sets in abruptly. The paralysis is rarely complete and groups 
of muscles onlj^ may be affected. As a rule, the paralysis comes on 
abruptly, but it may come on slowly, taking several days to develop. 
In a few weeks, atrophy sets in and the Hmb becomes flaccid, soft and 
wasted. The paralysis remains stationary for a time when improvement 
takes place, but complete recoverj^ is rare. Sometimes the growth of the 
bone of the affected hmb is impaired. Usually there are no sensory dis- 
turbances and the bladder and rectum are not affected. The condition 
of the reflexes is dependent upon the extent of involvement of the cor- 
nual cells. Occasionally the bulbar muscles are affected. 

Diagnosis. — This is not difficult except in the early stages. Care- 
ful study of the case is commonly all that is necessary. Landry's paraly- 
sis and peripheral neuritis are to be differentiated. 

Prognosis. — Complete recovery is rare. Improvement is the rule. 
Ivie^ tabulates sixteen cases, all showing good results. W. B. Davis 
reports a case cured by six months treatment and still well after three 
years. T. M. King" one case cured and one greatly benefited and A. S. 
Craig^ one much helped. Florence Gair, F. P. Millard, A. G. Walms- 
ley and others report gratifying results in many cases. 

Treatment. — In the treatment of chronic cases, F. P. Millard^ says 
"Five minutes' time is sufficiently long in treating a patient, and some- 
times too long. * * * Start in and move every spinal joint. That 
takes about two minutes. Spring the sacro-ihac articulations just enough 
to get motion. Then give a specific cervical treatment. Do not stop 
to relax muscles in a child. Adjust as rapidly as possible. Make every 
spinal joint yield to motion. Spend only one minute, or possibly two, 
on the cervical vertebrae. So far we have consumed four minutes. The 
last minute we loosen up the wrist or ankle, according to the extremities 
that are involved." This outHne has been followed with gratifying 
success by Gair, Green, Bush and others in many chronic cases. The pro- 
cedure in acute cases is condensed from A. G. Walmsley^: "Isolate, 

1. A. O. A. Case Reports, Series V. 

2. A. O. O. Case Reports, Scries I. 

3. Millard, Poliomyelitis. 



752 The Practice of Osteopathy 

keep cool and absolutely quiet. Stop all food until the temperature 
drops to 100° F. or lower and until the pain subsides when fruit juices 
may be given followed by heavier foods. Give patient all the water he 
will drink. Where the spine is sensitive, and it will be in many, use hot 
fomentations until a specific treatment can be given. If the fever is 
running high cool compresses will be grateful and help reduce tempera- 
ture. Irrigate the colon twice daily with saline water. Do this first 
thing when called. Later once daily will do and then discontinue. Look 
carefully to the nose and throat and wash with sahne or boracic solution. 
Keep feet warm as they may be cold even with high fever. Treat the 
case over a long period. See that he does not overdo and observe all 
dietetic and hygienic measures. " Both these men lay great stress on the 
importance of specific adjustments and massage of muscle tissue has little 
place in their treatment. This, with drill at home can be attended to 
by the mother. 

Ivie\ among other good ideas on treatment, gives the following: 
"May I suggest that when such severe results (the acute stage) follow a 
slight infection, that we may expect to find a lesion located at such a 
point as will interfere with one or more of the anterior root arteries which 
join and supply the anterior spinal plexuses. As there are only five or ten 
of the anterior root arteries (Dana), the lesions affecting them can be 
located throughout a wide range of the spine. In a great many cases we 
find that the correction of lesions well up in the dorsal and even in the 
cervical region have increased the amount of the improvement well 
beyond that received in the correction of the lumbar lesions alone. 
To promote resolution, correct the lesions, both muscular and bony, 
and relax the muscles of the spine daily; move every vertebra to the 
limit of all its possible motions; use flexion, extension, rotation, and lat- 
eral flexion at least once every day for at least a week; and help to over- 
come stasis by keeping the child off its back, turning it from side to side, 
and letting it lie on its stomach as much as possible. The limb, to be kept 
in its l)est condition, should be kept warm; treated gently; held in a 
natural position by the use of sand bags and clothes cradle, thus begin- 
ning early the prevention of deformity; the paralyzed muscles should 
not be kept on a stretch, as that will retard any possible improvement; 
stimulating rubs and baths should be given frequently. " In the chron- 
ic stage he advocates: "Now that the nerve cells have been given a 
chance to regenerate (removal of lesions), the best thing to do is to force 
them to work if possible. To do this, the so-called resistance exercises 

1. Journal of the American Osteopathic Association, February 1906. 



The Practice of Osteopathy 753 

or educational movements are to be strongly recommended; the 
idea being to place the limb in a given position and then ask the 
child to fix all its attention on the hmb and to earnestly attempt to 
hold it there while you move it, or to keep making the attempt while 
you move the limb through its whole range of motion in that direction. 
These movements should be so calculated that the resistance of the child 
will exercise the group of muscles affected. The mother or nurse can give 
these exercises every night on going to bed." 

Acute Ascending Paralysis 

(Landry's Paralysis) 

Definition. — An acute disease, characterized by an advancing 
paralysis, beginning in the legs, passing upward to the trunk and the 
arms and finally it may involve the centers in the medulla. Toxic 
and infectious influences that congest the nerve courses and ultimately 
destroy the cells seem to be the important factor. The anterior gray 
matter of the cord is involved, and it is probable that many cases are a 
form of acute poHomyelitis. The spleen is congested and in some 
instances the lymphatics. 

Etiology. — A definite cause has not been found, although osteo- 
pathic lesions are important predisposing factors. A toxic cause seems 
probable. The disease is most common in males between twenty and 
forty years of age. It may follow traumatism, exposure, cold or the in- 
fectious fevers. 

Symptoms. — Weakness of the lower extremities is generally the 
first symptom, though the arms may be involved first. This is shortly 
followed by paralysis. The paralysis then extends to the trunk and 
within a few days the arms are also affected. The muscles of the neck 
are next involved and finahy those of respiration, deglutition and articu- 
lation. The reflexes are aboHshed. The muscles are relaxed, but gen- 
erally do not waste or show electrical modification. Sensation is usually 
not affected, but there may be tingling, numbness, hyperesthesia and 
muscular tenderness. The sphincters are not involved as a rule. The 
spleen is usually enlarged. The course is variable. Death often occurs 
in from two days to a few weeks. When the improvement takes place, 
th(; part last affected recovers first. 

Diagnosis. — This is not always easy. It is sometimes impossible 
to differentiate between this disease and multiple neuritis. The his- 
tory, the motor paralysis, the absence of wasting and of electrical modi- 



754 The Practice of Osteopathy 

fication, as well as the absence of involvement of the spliincters, will 
definitely aid in the diagnosis. 

Prognosis. — The prognosis is unfavorable. A large majority of 
cases prove fatal. In a few cases treated osteopathically, results were 
favorable if the patient was seen earl}'. The muscles of the spinal col- 
umn were markedly contracted. 

Treatment. — The treatment of Landry's disease consists princi- 
pally of thorough treatment of the spine, especially of the lower dorsal 
and lumbar regions, and attention to the underlying toxic condition. 
The treatment should be most thorough; the vertebrae and ribs found 
disordered should be corrected and each vertebra should be care- 
fully separated (if conditions permit) from its neighbor. When the 
paralysis has extended to the trunk and neck, a thorough treatment all 
along the spinal column should be given with a view to relaxing the con- 
tracted muscles and to render flexible the entire spinal column, so that 
the cord may be properly nourished and the progress of the disease check- 
ed. Careful relaxation of the contracted spinal muscles unquestionably 
has a potent effect upon the cord circulation, which tends to check and 
retard degenerative processes. Treatment of the hmbs directly will be 
found a help, as well as direct treatment of all tissues paralyzed. If 
swallowing is impossible, the patient should be fed through the rectum, 
or by the stomach or nasal tube. See that the patient is carefully nursed. 
Massage is beneficial. 

Locomotor Ataxia 

(Tabes Dorsalis) 

Locomotor Ataxia is frequently met with. It is a disease of the 
spinal cord wherein the ultimate effect is a sclerosis of a progressive char- 
acter of the nerve courses of the posterior column. It is claimed that the 
origin is in the protoplasmic processes of the posterior spinal ganghon. 
The characteristic symptoms are incoordination, Ai'gyll Robertson 
pupil, Hghtning pains and loss of knee-jerk. 

Osteopatliic Etiology and Pathology. — Most cases develop be- 
tween the ages of thirty and forty, although it is occasionally seen in 
young men, and rarely in children from hereditary syphihs. Malefe are 
much more frequently affected than females (10 to 1, Osier), and the 
disease is much more frequent in cities. Predisposing causes are given 
as syphihs, prolonged exposure to wet and cold, and sexual excesses, 
although there is a disposition on the part of neurologists to confine 



The Peactice of Osteopathy 755 

the cause of true tabes to syphilis, some records showing as high as 90 
per cent, of the cases from that cause. Tabetic symptoms develop in 
from five to fifteen years after syphiHtic infection. There are no data to 
show the probable proportion of syphiKtic cases which later develop 
tabes, but it is undoubtedly small. As all cases of tabes examined by 
osteopaths show spinal lesions, it is reasonable to suppose that by inter- 
fering with the nutrition to the spinal cord, they allow consequent de- 
generation. It is also quite probable that osteopathic treatment for syph- 
ihs would, for the same reason, prevent sclerosis and resultant tabes. 
That syphilis is not the only cause, is also held by some authorities. Starr 
cites a true case from a severe blow in the dorsal region. Osteopathic 
observation would lead to a differentiation of tabes, according to the 
cause. Cases have been recorded, which simulated true tabes in most 
symptoms, which did not have a history of syphiHs. J. Knowles makes 
the point that probably certain cases simulating tabes have reached 
what might be called an irritation stage (pathologically) of the nerves 
and their centers, sclerotic changes not having taken place; and he be- 
lieves these cases would naturally yield to osteopathic treatment. Teall 
confirms tliis view by being of the opinion that these cases are the ones 
largely due to tramnatism, exhaustion or exposure, and the probabilities 
are t^at in time sclerotic changes would take place, resulting in true tabes. 
In such cases there can be no question as to the osteopathic lesion, which 
would be sufficient to materially interfere with the peripheral sensory 
nerves and disturb the protoplasmic processes to the spinal gangHa and 
sensor}^ tract. As a rule they are in the lower dorsal and lumbar regions. 
Cases are reported which had marked sacral and coccygeal lesions. 

Pathologically, Dana speaks of locomotor ataxia, "as a post- 
infective degeneration, which first attacks the posterior spinal ganglia 
or corresponding cells of the special senses, due to a prolonged poisoning 
of these parts by the toxins of the infection. " The first change is in the 
posterior roots. Without doubt osteopathic lesions can readily affect 
the nutrition of these roots. This is shown upon examination 
in cases where the vertebral lesions impinge the tissues surrounding the 
spinal nerve at its exit, (or otherwise damage nervous stimuli and cir- 
culation) and also where the displaced head of the rib crowds upwards 
against the spinal nerve and again where the rib impinges the correspond- 
ing sympathetic gangHon which lies anterior to the head of the rib. Very 
likely in many cases the syphilitic infection is an exciting factor, but it 
seems plausible that osteopathic lesions, traumatism, cold, exposure and 
excesses predispose by disturbing the circulation to involved areas. The 



756 The Practice of Osteopathy 

changes are at first inflammatory, followed by degenerative changes 
in the nerve com-ses wliich cause connective and neuroglia overgrowths 
to take the place of fibers in the sensory tract, and finally in the motor 
tract. Thus from the posterior ganglia, a section between the columns 
of Goll and Burdach is involved, and the progress of the sclerotic change 
is upward in the cord. The pia mater and coats of the vessels are thick- 
ened. The principal changes in the cord are in the lower dorsal and 
upper lumbar segments and the cord may be changed in shape. In long- 
standing cases there is degeneration of the ascending antero-lateral 
tract, of the direct cerebellar tract, and of the pyramidal tract. The 
cerebral changes in some cases consist of sclerosis in the restiform bodies 
in the inferior peduncles of the cerebellum, and of certain cranial nerves, 
especially the third, optic, vagus and auditory nerves, and also cortical 
changes may occur. 

Symptoms. — Authorities divide the sj^nptoms into three stages — 
the pre-ataxic, ataxic and paralytic. This division is largely an arbitrary 
one. Motor symptoms are usually the most prominent. There is 
inabihtj^ to coordinate the muscles. The patient first notices that he 
cannot walk steadily when in the dark or when he has his eyes closed. 
Later he finds that he cannot maintain his equilibrium even in daylight ; 
this is ascertained when the patient places his feet together and 
the eyes are closed (sign of Romberg). As a rule this is unaccom- 
panied by muscular wasting, so there is no loss of motor power. Soon 
the gait becomes characteristic ; in walking the feet are lifted high and are 
brought down heavily on the heel; the ball of the foot comes down last, 
producing what is called the "double step;" the walk is straddling; 
the limbs are thrown about, and there is staggering, due to incoordina- 
tion. Incoordination also develops in the hands, but usually later in 
the disease. Suddden involuntary movements and palsies are other 
motor sjTiiptoms. The latter occur in about twenty per cent of cases 
and as a rule are of short duration. Paralysis and muscular atrophy 
do not develop until after a few years. 

Pain is an early symptom and always present; it is of a darting, shoot- 
ing or stabbing character and appears in paroxysms. It is most 
common in the legs, lasting but a second or two, and often accompanied 
by a hot, burning feeling. Herpes may appear along the course of the 
nerve. Anesthesia and hyperesthesia of certain areas may occur. A 
girdle sensation may be a noticeable symptom. The muscular sense 
is more or less impaired; there is a feehng as if there were cotton between 
the patient's feet and the floor. Retardation of tactile sensation is a 



The Practice of Osteopathy 757 

common symptom. The power of localizing pain is often lost. The 
knee-jerk is lost early in the disease. Occasionally, however, cases 
are met where it is retained. The skin reflexes are also impaired; in 
some cases they may be increased at first, but later are sure to be in- 
volved with the deep reflexes. The piapi! does not respond to the light, 
but still accommodates for distance, constituting the Argyll Robertson 
pupil. Ptosis may develop with or without strabismus. Optic atrophy, 
which may lead to blindness, paresis of the ocular muscle, and contracted 
pupils, may occur. The ocular symptoms may appear early in the dis- 
ease. 

The visceral pains or crises are chiefly gastric and are sometimes 
accompanied by obstinate vomiting. Laryngeal, rectal, urethral and 
nephritic crises may occur, and at times are exceedingly severe. Laryn- 
geal crises may be manifested by intense dyspnea and noisy breathing. 
Constipation is common. There may be retention of the urine resulting 
m cystitis. Sexual power is generally lost early. 

Trophic changes occur later in the disease. The so-called arth- 
ropathies, or joint lesions, msLj occur at any period of the disease. It con- 
sists of an enlargement of the joints, associated with serous exudations, 
which rarely become purulent; atrophy of the heads of the bones; de- 
struction of the bones and cartilages; or spontaneous fracture or disloca- 
tion may occur, owing to the brittleness of the bones. There is no pain 
and the large joints are most frequently affected; these may be excited 
by an injury. Herpes, skin ecchjmioses, edema, local sweating, altera- 
tions in the nails, perforating ulcer of the foot, onychia, decay of the 
teeth and 'atrophy of the muscles may occur. The auditory nerve is 
rarely affected, but in some cases there may be deafness. There may 
be attacks of vertigo. Olfactory sjinptoms are rarely met with. Cere- 
bral symptoms are rare. Paralysis may develop and the patient be- 
comes bed-ridden. The disease itself does not prove fatal; the patient 
may live for years until some intercurrent disease causes death. 

Diagnosis. — This is usuall}^ easy when the characteristic symptoms 
are developed. The presence of hghtning pains, absence of the knee- 
jerk, early ocular palsies, a squint, ptosis and Argyll Robertson pupil 
make the diagnosis conclusive. Care has to be taken in making diag- 
nosis from peripheral neuritis, paresis, ataxic paraplegia, cerebral disease 
and some diseases in which the posterior columns are disturbed. 

Prognosis will depend largely on the exciting cause, as it is least 
hopeful from syphilis, but the earlier the case is treated the better the 



758 The Practice of Osteopathy 

chance. The progress of the disease can sometimes be arrested and 
occasionally cases presenting symptoms of the first and second stage 
are entirely relieved with persistent treatment. 

Treatment. — Experience in the treatment of locomotor ataxia 
has been that often the disease can be checked and the symptoms re- 
Heved; but curing a case of locomotor ataxia, except in the early stages, 
is seldom possible. When there is degeneration of nerve centers, there 
is no hope for a cure. Those with a syphilitic history are by far the 
hardest to relieve. Antisyphihtic treatment should be considered. 
Cases with a syphiUtic history presenting preataxic symptoms, Argyll 
Robertson pupil, lightning pains and loss of patellar reflex have been 
cured; unfortunately these cases are not always diagnosed. 

The treatment consists of thorough correction of the spinal derange- 
ments found, especially through the lumbar and lower dorsal regions. 
If the disease has involved the arms or brain, thorough treatment should 
be given the entire length of the spine with a view to increasing the cir- 
culation in the spinal cord and brain, and thus checking or prevent- 
ing the tissue degeneration. "In the early stage, deep massage to the 
muscles of the back promotes the flow of venous blood through the spinal 
vessels and their anastomotic branches, and is the best means of reheving 
the congestion which is supposed to exist. " (Starr) The lower spine 
will be found to be rigid and should be well sprung to get mobiHty. 

Careful treatment of the limbs should be given, but be exceed- 
ingly cautious in the treatment of the limbs of advanced cases, as there 
is considerable danger of producing fractures. Stretching the thigh 
muscles and internal and external rotation treatment of the legs should 
be given. See that the bowels are moved daily and be positive that 
there is no retention of the urine in the bladder. A catheter has to be 
used in some cases. The patient should be careful about taking too much 
food, and especially beware of indigestible food, as it irritates or excites 
gastric crises. 

Dming painful attacks the patient should rest in bed, and with 
careful treatment the attack can generally be reheved. Hot applications 
are of considerable aid. 

At all times excesses should be avoided. Occupation of some char- 
acter should be given the sufferer. Do not promise to cure the patient, 
and make it plain at the start that it will probably require a long time to 
show much improvement. Sj^stematic exercises to reestablish coordina- 
tion should not be neglected. 



The Practice of Osteopathy 759 

Hereditary Ataxia 

(Friedreich's Ataxia) 

This is a rare hereditary disease, due to sclerosis of the cohimns 
of GoU and Burdach and the pyramidal tracts. There are ataxia, mus- 
cular weakness, nystagmus, speech disorders and loss of knee flex. Al- 
most invariably there will be found a neuropathic history. Alcoholism, 
syphihs and insanity in the parents are predisposing causes. Tubercu- 
losis may be a factor. Acute diseases, especially infectious fevers, den- 
tition and injuries to the spine may be exciting causes. It occurs most 
frequently in males about the seventh or eighth year and very seldom 
after puberty. Several members of the same family are apt to be affected. 
The disorder is transmitted by the female. "The degeneration of the 
posterior and pyramidal columns seems to occur at the time of cord de- 
velopment, when malnutrition or hereditary dyscrasia would disturb 
it most. " 

Pathologically, "the spinal cord is smaller throughout than nor- 
mal; we have also a combined disease of the posterior and lateral tracts 
(Schultze), a degeneration of GoU's tract in toto, of Burdach's almost 
entirely, and of the direct cerebellar, the crossed pyramidal (?), and of 
Clarke's columns, in which we find not only atrophy of fibers, but also 
a degeneration of the gangHon cells. Gower's tract msiy Hkewise be in- 
volved." (Oppenheim). 

Symptoms. — Impaired coordination, beginning in the legs and 
later extending to the arms, is the first marked symptom. The gait is 
pecuUar; it is swaying and irregular and it lacks the pronounced stamping 
gait of locomotor ataxia. There is a loss of reflexes, while no sensory 
symptoms are present as a rule. The spliincters are normal. Nystagmus 
is present and is a characteristic s3Tiiptom. The speech is scanning. 
Tahpes and lateral curvature of the spine are common. The mind be- 
comes sluggish in later stages. The course is always very slow. 

Diagnosis. — This is not difficult as a rule, owing to the usual family 
histor}^ presented. The spinal curvature, nystagmus, incoordination, 
scanning speech, irregular gait, and deformity of the feet are symptomatic. 
In locomotor ataxia the gait, sharp pains, anesthesia and Ai-gyll Robert- 
son pupil will differentiate between the two. Differentiation will also 
have to b(> made from chorea, ataxic paraplegia and multiple sclerosis. 

Treatment. — The same treatment as in locomotor ataxia is fol- 
lowed. Lesions presented have been found at the tenth and eleventh 
dorsals, and at the second and third cervicals, although, as a rule, the en- 



760 The Practice of Osteopathy 

tire spinal column is quite debilitated. Some improvement will be noted 
in these cases, but not much can be expected from treatment; contrac- 
tures may be prevented. 

Spastic Paraplegia 

Spastic paraplegia begins as a stiffness in the legs, with no sensory- 
symptoms, but finally the muscles become rigid and slowly paralyzed. 
The reflexes are exaggerated. 

It may occur, in a few instances, as a primary disease, "being a de- 
generation of the motor neurone, whose body lies in the brain cortex and 
whose axone lies in the lateral pyramidal tract. " Usually it is secondary 
to tumors, inflammation and softening of the brain. Multiple sclerosis, 
hemorrhage, transverse myelitis, syringomyelia and other diseases of the 
cord, injur}^, exposure and overexertion are exciting causes. Syphihs 
may be a cause. It generally develops between the ages of twenty and 
forty. 

Pathologically, the degeneration involves the lateral pyramidal 
columns of the cord. It begins at the periphery and extends upward 
until finally the axones atrophy and neuroglia overgrowth takes place 
and sclerosis of the motor tracts results. 

Symptoms. — Muscular stiffness in one leg is usually the first symp- 
tom, which gradually disturbs both sides. The muscular stiffness in- 
creases to a rigidity, and even cramps, so that it is with considerable diffi- 
culty that the patient moves about. The reflexes are exaggerated. The 
joints, as well as the muscles are stiff, so that the toes are dragged upon 
the ground and the legs are kept close together, abduction of the limbs 
being difficult. On the whole, there is much tiredness, stiffness, rigidity 
and hardness of the leg muscles, so that all motions with them are per- 
formed with great effort. Sensory and trophic symptoms are lacking; 
control of the bladder and rectum is usually normal. The progress 
of the disease is slow. The upper extremities may be involved in after 
years, but the common extensive disturbance is with the legs, so that they 
may be entirely useless and the muscles atrophy from disuse, although 
rigidity and contractures remain. 

Treatment. — The prognosis is usually unfavorable, though fre- 
quently the patient may be considerably benefited. A few cases that 
have been caused by traumatism, cold or exposure have yielded to 
osteopathic treatment and all symptoms disappeared. The treatment is 
largely that of locomotor ataxia. The lesions are readil}' located in the 
spinal column. In a few cases a slight posterior curvature of the dorso- 



The Practice of Osteopathy 761 

lumbar region is found, but the majority of the lesions are in the lower 
dorsal region. Special care should be given to the bladder and bowels. 
Prolonged warm baths are beneficial. Treatment of the legs is always 
secondary to that of the spine. The diet should be nutritious and one 
easily digested. Give the patient plenty of fresh air and sunhght with 
cheerful surroundings. E. C. Link reports two cases, one of over one 
year's standing, completely recovered, and another much improved. 

Ataxic Paraplegia 

In ataxic paraplegia there are ataxic and spastic symptoms, due 
to both posterior and lateral sclerosis. Traumatism, cold and exposure 
are etiologic factors. It is found in diffuse myelitis, general paresis, lepto- 
meningitis and in toxic conditions as in pernicious anemia. The pos- 
terior and lateral columns are degenerated, so that in the former there 
is an ascending degeneration and in the latter a descending. 

Symptoms. — These comprise those of tabes and spastic para- 
plegia. Incoordination, ataxia, Hghtning pains, anesthesia, rigidness 
of muscles and exaggerated reflexes are the principal symptoms. The 
muscles easily fatigue; sensory symptoms are not so troublesome as in 
tabes; there may be \isceral crises, sometimes Argyll Robertson pupil;' 
and possibly spasms of the upper extremities and jaw. The course of 
the disease is slow. 

Diagnosis. — This is not difficult as a rule. First, there is ataxia; 
then increased reflexes, fatigue of the muscles and paraplegia. Tumor 
of the cerebellum maj^ confuse the diagnosis. 

Treatment. — There is frequently a chance to greatly benefit these 
cases, and even in some instances a cure may be performed, provided the 
case is seen early. Thorough treatment of the spine to relax the mus- 
cles and to adjust the ribs and vertebrae is the indication. Stretching the 
spine, if carefully done, is beneficial. Muscular manipulation improves 
the spinal cord circulation, and osseous correction removes probable 
impingements to nutrient channels and nervous influences induced by 
cold, exposure, traumatism and secondarj^ disturbances. Care of the 
general health, hygiene, diet, etc., are important. 

Syringomyelia 

Definition. — A chronic affection of the spinal cord in which there 
is an cnihryonal neurogliar overgrowth about the central canal, with 
cavity formation. It is characterized, clinically, by progressive mus- 
1. Journal of Osteopathy, Oct. 1904. 



762 The Practice of Osteopathy 

cular atrophy, peculiar disturbances of sensation and various trophic 
and vasomotor disorders. The onset generally takes place before the 
thirtieth year. Males are much more commonly affected than females. 
It is claimed by some that the disease is infectious. It frequently fol- 
lows trauma. 

Pathologically, the condition begins with an overgrowth of em- 
bryonal neurogUar tissue. This is followed by degeneration of the 
gliomatous tissue with a formation of cavities, or this cavity formation 
may be the result of hemorrhage. The disease, in most cases, involves 
only the cervical or dorsal regions, and is usually in the posterior or 
postero-lateral tracts. The cavity may prevail throughout the entire 
cord, but usually only the cervical and dorsal regions are involved. 
The cavities lie in the gray matter outside of the canal. 

Symptoms. — The onset is slow. The symptoms depend upon the 
situation and extent of the cavity. As the disease most frequently in- 
volves the cervical region, the neck and arms are usually affected. At 
first neuralgic pains may develop in the muscles. Later there is progress- 
ive muscular atrophy and loss of painful and thermic sensations. Tac- 
tile and muscular senses are usually intact. The reflexes are increased 
and a spastic condition is present. The lower limbs usually escape, but 
when they are involved the cHnical picture may be that of amyotrophic 
lateral sclerosis. A lateral curvature is present. When the disease 
extends into the medulla, there will be various bulbar symptoms. Tro- 
phic changes and vasomotor disorders are common. 

A form of syringomyelia, known as Morvan's disease, is charac- 
terized by neuralgic pains, cutaneous anesthesia and painless felons. 

Diagnosis. — The progressive muscular atrophy, the retention of 
muscular and tactile senses, and the loss of thermic and painful sensations 
are typical symptoms. The diseases with which it may be confounded 
are: Cervical Pachymeningitis. The pain is usually greater, the 
tactile sense is lost and it runs a more rapid course. Anesthetic Leprosy. 
The trophic changes are more marked, tactile sensation is lost and the 
phalanges often drop off. Progressive Muscular Atrophy and Amyo- 
trophic Lateral Sclerosis. Sensory symptoms are wanting. 

Prognosis. — The prognosis is unfavorable. Duration is from five 
to twenty years. 

Treatment. — Little can be done except attending to the diet and 
hygiene of the patient and meeting urgent symptoms. Probably, con- 
tinued treatment along the spinal column would influence to some ex- 
tent the circulation of the cord in the region of the involvement. Hot 



The Peactice of Osteopathy /63 

applications are of value in relieving pain and cramps. The X-ray has 
proven of some benefit in checking the progress of the disease. 

Amyotrophic Lateral Sclerosis 

"This is a chronic, progressive form of spinal paralysis, character- 
ized by the symptoms of progressive muscular atrophy in the arms and 
by lateral sclerosis or spastic paraplegia in the legs. " (Starr). It is sim- 
ilar to progressive muscular atrophy, except, in addition, there is sclerosis 
of the pyramidal tract. (See Progressive Muscular Atrophy.) Osier 
classes progressive muscular atrophy of spinal origin, amyotrophic 
lateral sclerosis and progressive bulbar paralysis as diseases of the whole 
efferent or motor tract, wherein these disorders may simply be various 
stages in the same case. He says, "A slow, atrophic change in the motor 
neurones is the anatomical basis, and the disease is one of the whole 
motor path, involving, in many cases, the cortical, bulbar, and spinal 
centers. " There can be no question that for the student, a classification 
of spinal cord diseases according to the whole motor tract, the upper 
motor segment, the lower motor segment, etc., is a scientific classification 
from our present knowledge of the histology and physiology of the neu- 
rone, but for clinical purposes the usual classification is given. Osteo- 
pathically, we are greatly in need of a new nosology, either according to 
the cause of the disorder or to the physiological disturbance. 

Amyotrophic lateral sclerosis does not occur so frequently as pro- 
gressive muscular atrophy. Heredity plays a part, and it affects older 
people. Injury to the spinal column is undoubtedly an important 
factor. Exposure and cold may be exciting causes. Infectious diseases 
and syphilis are probably important causes. 

Pathologically, there are atrophy in the anterior cornu and scle- 
rosis of the crossed and direct pyramidal tracts. There is sclerosis of cen- 
ters in the medulla. 

Symptoms. — Atonic atrophy, muscular weakness and fibrillar}'- 
contractions, of varying degrees, are characteristic. The reflexes are ex- 
aggerated; the arm and leg muscles become weak and finally rigid and 
atrophied. This results in deformity. Disturbances of sensation are 
not pronounced. The sphincters may be slightly affected. 

Diagnosis. — The disease is not so prolonged as progressive muscu- 
lar atrophy. Differentiation has to be made from multiple arthritis and 
transverse myelitis and s^aingomyelia. 

Treatment. — The same treatment as outlined for progressive mus- 
cular atrophy is indicated. The disease may bo retarded and life pro- 
longed. 



"64 



The Practice of Osteopathy 



Progressive Muscular Atrophy 

A disease characterized by a slow, but progressive, loss of power 
and by muscular atrophy. Anatomically, it is characterized by de- 
generation of the gangHon cells of the gray matter in the cord. This 
atropliic affection develops just opposite to that of chronic anterior pol- 
iomj-ehtis. It is commonly a disease of males in middle life. Syphihs, 
rheumatism and lead poisoning predispose. It sometimes foUows cold, 
wet, exposure, traumatism, mental worries, overuse of certain muscles,, 
or prolonged emotional excitement. Hereditary influences are present 
in some cases. In all cases lesions are detected in the vertebrae and 
ribs, corresponding to the innervation of the diseased areas. Very 
likelj' these lesions are the starting point of the disease, by impairing nu- 
trition to the motor cells of the anterior cornu, and thus resulting in 
atrophy. 

Pathologically, the muscles are wasted, the fibers undergo fatty 
degeneration and there is an overgrowth of connective tissue. The 
peripheral motor fibers are degenerated. The anterior nerve roots 
leading to the horns are atrophied. The large gangUon cells of the an- 
terior horns are atrophied, or even entirely removed. The neuroghar 
tissue is increased. There is sclerosis of the anterior and lateral pj'ra- 
midal tracts of the cord in the majorit}- of cases. (See Amyotrophic 
Lateral Sclerosis). The pyramidal tracts have been found degenerated 
through the pons and internal capsule, even up to the motor cortex. When 
bulbar sjonptoms are present, there is degeneration of the motor nuclei 
of the medulla. The posterior columns are not involved. 

Symptoms. — IrregTilar pains, numbness or exhaustion are usually 
felt in the region that is soon to become wasted. The upper extremities 
are first affected. The muscles of the ball of the thumb waste first, then 
the interossei. From atrophy of the interossei and lumbricales and 
contraction of the long extensor and flexor muscles, the deformity known 
as "claw hand" results. The wasting creeps up from the forearm, arm 
and shoulder. The muscles of the trunk are gradually affected. The 
muscles of the lower extremity may escape entirely. The platysma 
myoides does not waste and is often hypertrophied. The face muscles 
are attacked late or not at all. The affected muscles often twitch. De- 
formities and contractm-es develop, notably lordosis. Sensation is not 
impaired although the patient may complain of numbness and coldness. 
The bladder and rectum are not affected, but sexual power may be lost. 
The paralysis is flaccid and the reflexes absent in the so-called atonic 



The Practice of Osteopathy 765 

cases. In atonic atrophj^ there is more or less spasm, the reflexes are 
greatly increased, there are often contractm'es and the wasting is usually 
trifling. 

Diagnosis. — Differential diagnosis has to be made from syringomye- 
ha, chronic anterior poUomyehtis, lead palsy and muscular dystrophies. 

Prognosis. — The prognosis of progressive muscular atrophy is not 
favorable, although a number of cases have been greatly helped by an 
extended course of treatment. 

Treatment. — The treatment consists of a thorough, stimulating 
treatment of the innervation of the affected regions, with manipulation 
of the muscles and parts diseased. Correction of the lesions to the 
vertebrae and ribs, which are involving the innervation to the diseased 
tissues, is of primary importance. A cure cannot be expected when de- 
generation of the nerve centers has occurred; still, the progress of the 
disease may be checked in many cases, and the patient occasionally gain 
considerable strength. When atrophy starts in the muscles of the ball 
of the thumb, the lesion is to the median nerve, and derangements of 
the cervical vertebrae, from the fifth to the seventh, may be found. At- 
tention to the general health is important Outdoor hfe is preferable and 
gymnastic exercises are of value, but do not overtax the strength. 

Bulbar Paralysis 

(Labioglossolaeyngeal Paralysis) 

A progressive atrophy and paralysis, invading the lips, tongue, 
pharynx and larynx, due to involvement (sclerosis) of the motor nuclei 
of the medulla oblongata that supply these tissues. It is rarely pri- 
mary, more frequently secondary to tabes, amyotrophic lateral scle- 
rosis and diseases involving the motor nuclei of the medulla. Diph- 
theria, syphihs and lead poisoning are said to predispose. Osteopathic 
lesions of the upper cervical are also important factors in many cases. 
Halbert says: "The nuclei of the hypoglossal, the spinal accessory, 
the facial and the motor part of the trifacial nerves suffer most decidedly 
from the sclerotic degeneration. The nerve trunks and the muscles which 
they supply gradually show the effects of a similar degeneration." 

The acute form results from hemorrhage, embolism or inflamma- 
tory softening. The onset is usually sudden. The speech is difficult 
or entirely lost. There are dribbling of sahva, difficult swallowing, 
flabbiness and flaccidity of the lips and frequent choking spells occur. 
These cases may prove rapidly fatal. 



766 



The Practice of Osteopathy 



w 



The chronic form may result from progressive muscular atrophy, 
insular sclerosis, amyotrophic lateral sclerosis, acute ascending paralysis 
or chronic poUomyelitis. The paralysis starts in the tongue, the first 
symptom being a shght defect in the speech. When the Hps become 
involved, the patient cannot whistle and speech is rendered still more 
difficult. The hps are prominent and the lower one drops. The saUva is 
increased in amount and there is drooHng. Mastication of the food 
becomes difficult. The tongue becomes atrophied and the mucous 
membrane wrinkled. Fibrillary tremors of the lips and tongue are pres- 
ent. Sensory symptoms are not present. Taste is normal. Paralj^sis 
of the larynx is not so pronounced as of the other parts. 

Diagnosis. — This is generallj^ easy as the symptoms are well mark- 
ed. The prognosis is unfavorable. 

Treatment. — Little can be done in the majority of cases. Only in 
those cases where the paralysis is caused by cervical lesions can much 
hope be given. Derangements of the cervical vertebrae, especially the 
atlas and axis, occa.sionally influence the circulation in the medulla to 
such an extent that the motor nuclei are greatly involved. The sub- 
luxated vertebrae may interfere with the blood-vessels directly or through 
the vasomotor and trophic nerves. When the onset is not abrupt, the 
prognosis is more favorable. When deglutition is impaired, the stom- 
ach tube should be used in feeding the patient to prevent the food pass- 
ing into the trachea. 



The Practice of Osteopathy 767 

ORTHOPEDIC SURGERY 

By H. S. Hain 

Orthopedic surgery deals with the mechanical or surgical prevention 
and correction of all deformities, especially those of children. It is 
not alone justifiable, but imperative, that orthopedic surgery be given 
a prominent position in any vip-to-date text on the Principles and Prac- 
tice of Osteopathy. The justification is threefold: though orthopedics 
was practiced to a limited extent before the Science of Osteopathy was 
developed, it has always been considered to be outside the realms of true 
surgery, in that it is practically bloodless, and those engaged in such 
practice have sought to establish it upon a platform of its own. 

The basis of the practice of orthopedic surgery and osteopathy is 
similar, if not identical, in that it deals almost entirely with bony abnor- 
maHties. It is recognized by the whole osteopathic profession, and 
unconsciously by some adherents of medical science, that the maintain- 
ance and restoration of normal function are alike dependent on a force 
inherent in bioplasm and that function perverted beyond the limits of 
self-adjustment, is dependent upon a condition of structure perverted 
beyond those Umits. This, then is the platform upon which the two sci- 
ences of osteopathy and orthopedic surgery are erected. 

The technique of osteopathic practice consists of passive manipu- 
lative measures, designed to render to the organism such aid as will en- 
able it to overcome or adapt itself to the disturbed structure; and does 
not seek, in itself, the aid of any instrument, mechanical appliance or 
plaster of Paris cast. 

Surely it is but a short step from our osteopathic therapeutics to 
a system of therapeutics where we find all sorts of mechanical and plaster 
of paris appliances, etc., to help our passive manipulation in rendering to 
the human organism such aid as will enable it to overcome or adapt itself 
to a disturbed structure. This latter, of course, is the modern science of 
orthopedic surgery, and because of the shortness of this step, I insist that 
it is one of the most valuable adjuncts of the science of osteopathy, 
it is frequently necessarj^ for the osteopathic practitioner to take this 
step as conditions are met with that have progressed beyond the possi- 
])ihties of passive manipulations and again other conditions of perverted 
structure can be much more quickly reduced by the aid of each. 

It is then indisputable that the therapist who approaches disease 
from the osteopathic standpoint, above enunciated, is far more competent 



768 The Practice of Osteopathy 

to deal with the mechanical problems of orthopedic surgery than any 
other known therapist. Secondly, in many conditions originally treated 
by orthopedic methods, subsequent ordinary osteopathic manipulations 
obtain a much more satisfactory and more lasting result than if it is 
withheld. Thirdly, in order to avoid possible error, it is of extreme im- 
portance that all osteopathic practitioners be particularly famiUar with 
the conditions hereinafter described, more especially tubercular condi- 
tions of the spine, bones and joints, primary spinal curvatures and others. 

It is reasonable and furthermore true that osteopathic physicians 
are confronted in practice with an unusually large percentage of cases 
indicated above, and the early recognition of such conditions is of fun- 
damental importance in order that osteopathic manipulations be with- 
held and supplemented or replaced by orthopedic methods. 

Space of course will not permit of the entire discussion of this vast 
subject but the most important and serious conditions met with in gen- 
eral practice are fully discussed in the following pages of this chapter. 

Perhaps the commonest condition coming under this line of thera- 
peutics, and one in w-hich we, as osteopaths, are most vitally interested 
is rotary lateral curvature of the spine. From my personal observation 
and from experiences of some of the most prominent members of our 
profession, I am led to beUeve that this is one of our most difficult lesions 
to overcome osteopathically, hence my desire to go further into this 
condition than most of us might expect. I had opportunity to obtain 
personally some verj^ valuable information from Dr. Joachim Stahl 
in the King's Charity Hospital in Berhn, and to him I am deeply 
grateful for many of the ideas of treatment presented in the following 
article. I believe that I have an accurate conception of the patho- 
logical condition that exists in connection with this deformitj^ and I 
beUeve that my treatment of it has been more successful than any that 
I have seen under other methods, in that I have gotten most excellent 
results, in selected cases, in a comparatively short time, entirely be- 
cause osteopathic manipulations and exercises were used in connection 
with the modified Abbott method. 

Scoliosis or Rotary Lateral Curvature 

Scoliosis or Lateral Curvature of the Spine is a deformity where 
the spine is deviated in w^hole or in part to one or the other side of the 
median line, which deviation is accompanied by an element of rotation. 
Though usually considered as a spinal deformity its effects are obvious 
outside the spinal area in so much as it will cause deformity of the pel- 



The Practice of Osteopathy 769 

vis, legs, ribs, sternum, scapulae, and in severe cases, of the thoracic 
and abdominal viscera. 

Curvatures of the spine are the result of one of two distinct factors: 
first where there is a primary disease of the bone causing more or less 
destruction of the bone and spinal articulations, and resulting in per- 
manent spinal curvature. The most common example of this condition 
is seen in the angular curvature of Pott's disease. Rickets is usually 
responsible for a general long posterior curvature of the whole spine, as 
is osteomalacia with the superimposition of some lateral deviation. Fur- 
ther, any type of inflammation or trauma is capable of producing curva- 
tures of various types. Second, where there is no primary disease of 
the bone, joints, or ligaments, and where the curvature is due to exter- 
nal forces acting constantly or at frequently recurring intervals on the 
spine. 

Scoliosis or lateral curvature belongs to the second class. It is un- 
fortunately necessary to further subdivide scoliosis into two classes; 
one where the curvature is a position permanently maintained but cap- 
able of being reproduced by extreme physiological movement of a nor- 
mal spine, and secondly, a position which no normal spine can assume 
and which necessarily implies a change in the normal shape of the bones 
and intervertebral discs. The first may be described as a functional or 
postural lateral curvature, and the second as an organic or structural lat- 
eral cm-vature. Further, I might say that the first type may progress 
until it becomes the organic type. 

Pathology. — In scoliosis the spine undergoes not only curvature 
or lateral deviation but also rotation of the vertebral bodies which you 
will note always takes place towards the convexity of the curve. 

Changes in the Individual Vertebrae. — ^The bodies may be 
cither wedge shaped or lozenge shaped. In wedge shaped vertebrae, the 
bodies are compressed on the concave side and extended on the convex 
side, the intervertebral discs being atrophied on the shortened side. 
In the lozenge shaped type, the change in the bodies is most marked at 
the junction of the opposite curves, and is thus more commonly observed 
in compound curvatures. The pedicles are duected more antero-pos- 
teriorly on the convex side and more transversely on the concave side. 
The transverse processes on the convex side are more antero-posterior 
than normal, causing the vertical furrow between them and the spine 
to be narrower on this side. The spines point towards the concavity in 
structural curvatures and toward the convexity in the functional type. 
The vertebral foramen is rounded in the convexitj^ and pointed in the 



770 The Practice of Osteopathy 

concavity. The edge of the anterior common Ugament toward the con- 
vexity is greatly thinned while it has a well marked edge on the concave 
border. A fibrous degeneration occurs in the muscles on the convexity 
owing to stretching, while atrophy from disuse takes place in those on 
the concave side. 

Associated changes in tlie Viscera. — The dorso-lumbar curva- 
vature decrease in the volume of the lower thorax on the dorso-convex 
side tends to cause pleural adhesions with obliteration of the pleural 
sac and consequent collapse. Tuberculosis of the lung is common in 
patients who suffer from scoliosis. The lieart is often overworked but 
the above lessening of the pulmonary area in turn results in hypertrophy 
and dilatation of the right ventricle and subsequent general venous 
stasis. The itidney on the convex side is compressed, and as a result 
degenerative changes are prone to occur. Thd spleen is frequently dis- 
placed upward and is liable to pathological changes. Organs such as the 
stomach, transverse colon, esophagus and trachea are frequently dis- 
placed owing to the bony deformity and are thereby more prone to patho- 
logical change. 

Etiology. — The essential factor in the production of scoliosis is 
spinal insufficiency, which includes spinal muscles and ligaments as well 
as the bones. In many instances, however, the following factors have 
an important augmenting or predisposing effect. 

1. Occupational Deformity. — Primarily under this classifica- 
tion, I have found faulty positions adopted by school children as being 
the most comfortable, to be perhaps most important. Occupations such 
as those of nurse-maids, hod carriers, or stone cutters, are apt to induce 
scoliosis. 

2. Diseases of the Central Nervous System. — Unilateral 
weakness or paralysis of the muscles of the trunk are common causes 
of scoliosis. Anterior poliomyelitis plays a particularly important 
part as it may induce deformity by distortion of the lower extremity 
or by any inequality in the length of the limbs due to retardation of 
growth, as well as inducing general weakness of the muscles of the trunk. 
Other nervous disorders that should be considered are spastic pari ay sis, 
locomotor ataxia, syringomyelia and Friedreich's ataxia. 

3. Incidental Deformity.^ — Scoliosis may be caused b}^ direct 
injury or by fracture, Pott's Disease, or organic affections of the spine. 
Marked deformity caused by Sciatica or lumbar neuritis, if persistent 
may finally induce permanent deformity. 



The Practice of Osteopathy 771 

4. Deformities Due to Diseases of tlie Cliest. — In empyema 
or pleurisy one side of the chest is retracted and it will be noticed that 
the curvature occurs toward the healthy side. Chronic pulmonary 
tuberculosis producing fibrosis of the lung gives the same result as em- 
pyema and pleurisy. 

5. Deformiity due to obliquity of tlie pelvis. — This type may 
be due to any inequality of the limbs, such as equinus of the foot. Con- 
genital dislocation of the hip may play a part while one naturally lays 
stress on pelvic and lower lumbar lesions. 

6. Deformity due to Distortion of Other Parts. — Unequal 
visions, unequal hearing, and torticolHs by causing malposition are etio- 
logical factors especially in school children. The loss of an arm will 
tend to cause an asymmetrical position of the trunk. 

7. Congenital Deformity. — Congenital scoHosis occurs, but is 
usually associated with other congenital deformities of the spine, such 
as the reduction or increase of the vertebree, cervical rib, elevation of the 
scapula, etc. The deformity is usually not apparent until later years, 
though it may occur at birth. 

8. Spinal Lesions. — Any osteopathic lesion predisposes to cur- 
vature because it interferes with the nerve supply and tonicity of the 
spinal muscles and could readily cause the faulty position. 

Functional or Postural Lateral Curvature 

This is a condition where there is a gradual curve to one side unac- 
companied by any marked rotation. The maximum deviation may be 
no more than one inch and a half from the middle line, which point is 
generally found about the tenth dorsal vertebra. In the vast majority 
of cases deviation is to the left and in such the following alterations will 
be noticed: a general convex cm-ve to the left; elevation, and anterior 
displacement of the left shoulder; posterior displacement of the right 
shoulder; in extension, the right side of the back will be higher than the 
left and in addition some torsion to the concave side, which is easily under- 
stood if one recalls the exact changes that take place during side move- 
ment of the normal spine. It is important to remember that functional 
scoliosis disappears when the patient is suspended or assumes the re- 
cumbent position. 

Organic or Structural Scoliosis 

This term is applied to cases where definite change has taken place 
in the vertebra3. Organic curves may be simple when the deviation is 
unaccompanied by any compensatory curve, or compound when a com- 



772 The Practice of Osteopathy 

pensatory curve is present. We shall consider the deformities as they 
present themselves in the various regions of the spine. 

Cervico-Dorsal Curvature. — This condition is comparatively 
rare and according to Lovett occurs in only three and six tenths per cent 
of cases. The head is slightty deviated towards the concave side, the 
shoulder on the concave side is lowered, while on the opposite side or the 
side of the convexity it is naturally at a higher level. The angles of the 
upper ribs are prominent due to the co-existing rotation. 

The Dorsal Curvature. — The shoulder is raised on the convex 
side, and the rotation of the vertebrse is very marked, causing a very 
definite projection of the angles of the ribs on the convexity. This 
rotation also projects the scapula backwards on the convex side. On 
the concave side the scapula is flat and sunken, and the inferior angle 
rotated inwards and at a higher level than the opposite side. Viewed 
from the front the thorax may not be displaced at all, or it may be dis- 
placed toward the convex side, and if the latter is the case it is, of course 
more prominent on the concave side. In severe cases the lower end of 
the sternum is deviated towards the convexity and you will find that 
usually the arm hangs further from the convex side than from the op- 
posite one. 

The Lumbar Curvature. — Here we find the trunk displaced to- 
ward the side of the convexity, and the waist retracted on the opposite 
side. The difference in the level of the hips is the most prominent de- 
formity in this region, and it will be found that the hips are raised on the 
concave side. Rotation in this region is much less evident than in the 
dorsal region, but can be demonstrated by a fullness on the convex side 
of the curve, due to the projection of the transverse processes. 

Dorso-Lumbar Curvatures. — This condition is similar to a cer- 
tain extent, to a severe functional scoliosis. The findings observed in 
the last two regions above described will naturally be present in this 
type of curvature. It is not so frequently associated with compensa- 
tory curves as in the other types described. 

Compound Structural Curves. — The appearance in this type 
of scoliosis will, of course, be a combination of those described above 
according to the types of curvature in combination, that is to say right 
dorsal and left lumbar, etc. If one type predominates the appearance 
will be chiefly that found in that particular type of curvature. The 
relative frequency of the common type, as given by Schaltless, in eleven 
hundred and thirty seven cases is as follows; functional scoliosis, 15.39%; 
lumbar, 11.7%; dorsal, 19%; dorso-lumbar, 20%; cervico-dorsal, 3.6%; 
compound, 30%. 



The Practice of Osteopathy 773 

Diagnosis. — To the osteopathic physician the diagnosis of scol- 
iosis is not difficult. Let me caution you that true scoliosis must be 
distinguished from th6 lateral curvatures caused by Pott's disease. 
Vertebral rotation, the absence of pain, the extreme rigidity, the char- 
acteristic appearance of the ribs and thorax should, however, make the 
diagnosis of scoliosis easy. 

Treatment. — In general the treatment of scoliosis is difficult to 
present, because every case is considerably different, and the amount of 
correcting force used in any form is almost entirely a matter of judg- 
ment, as is also the time when corrective pressure should be discon- 
tinued. Continual practice in the treatment of these conditions is most 
essential to your success with them. I have had most gratifying results 
in a comparativel}^ short time simply because I used osteopathic treat- 
ment and exercises along with a modified Abbott method. 

Functional or False Scoliosis 

The functional or false scoliosis might be regarded as a habitual 
inability to stand correctly, simply a postural malposition and lack of 
muscle tone without marked structural change, which is maintained 
for a considerable length of time or where the position is repeated several 
times daily. The treatment of selected t3^pes of this deformity is most 
successful and may well be divided into three procedures: first, the 
substitution of a correct attitude for the faulty one, that is careful investi- 
gation should be made to ascertain the condition which might be the cause 
of the incorrect position such as poor school desks which might cause 
the child to reach either up or down to write, poorly fitting clothing which 
causes a pulling on the shoulder, eye strain which would cause tilting or 
twisting of the neck, congenital shortening of one limb or too rapid growth, 
should all be looked for and removed ; second, regular osteopathic manip- 
ulation, at least three times per week to increase the tonicitj'' of the 
already weakened spinal muscles and aid correction, are highly essential 
and shortens the time required for a complete cure; third, supervised 
gymnastic exercises of various kinds are very beneficial to develop and 
bring the musculature back to normal. Such simple exercises as crawl- 
ing on the hands and knees in a small circle towards the side of the con- 
vexity, and the hanging from a horizontal bar by the arm on the side of 
the concavity will prove to be helpful. Some authors recommend the 
regular army setting up exercises for some cases or a frame by means of 
which the hips are fixed, and rotating and side bending exercises of the 
head and trunk given. These last two exercises are indeed very rea- 



774 The Practice of Osteopathy 

sonable procedures but I have found them unnecessary mainly because 
I used osteopathic manipulations instead. 

In advising and supervising exercises it is best to have the patient's 
back bared so that the effect of each movement can be noticed and the 
exercises directed accordingly. Care and judgment should be used as 
to the number and severity of the exercises and would depend of course 
on the vigor of the child. Treatment should continue until the condi- 
tion has been overcome, and the patient should be under observation for 
a couple of months afterwards so that any recurrence of the deformity 
would be noticed and attended. 

Organic or Structural Scoliosis 

The treatment of organic or structural scoliosis is more complicated 
for it must be remembered there are two elements of the deformity de- 
manding correction; one, the lateral curve to be corrected by a side 
force, and the other, the rotation of the vertebrae to be corrected by a 
twisting force. I find both osteopathic manipulation and gymnastic 
exercises are of great value in the correction of this deformity as they 
help to loosen the curve and develop the musculature but used alone 
good results can rarely he obtained especially in obstinate curvatures. 
I believe that I have improved nutrition and probably prevented further 
deformity by treatments and exercises, but I am quite positive that it 
is not possible to correct an organic scoliosis without the forcible cor- 
rection used in the Abbott method. 

As the details of treatment are tedious to follow, we will take for 
example a case of right dorsal curvature presenting a marked hump de- 
formity, with a compensatory curve to the left in the lumbar region, as 
this is the most common type. I might say here that whether or not a 
compensatory curve is present, makes no difference, as treatment is di- 
rected entirely to the primary curve on the assumption that overcor- 
rection of it will cause a secondary curve to disappear by compensation. 

The patient is prepared by putting on a snug fitting undershirt and 
sewing pads of saddler's felt over all bony prominences, especially the 
crest of the ileum and anterior superior spine. Sometimes I take a piece 
of felt of four or five inches wide and long enough to go around the en- 
tire pelvis, just high enough to cover the brim, and fasten it in front 
with adhesive. Next I make a bunch of pads two or three inches in 
thickness and large enough to fill up the concavity of the left side, and 
first sew them together, and then with a few stitches fasten them to the 
undershirt thereby filhng up the space on the concave side. The edges 



The Practice of Osteopathy 



775 



of the pads should, of course, be trimmed down to conform with the 
general contour of the body, the main thickness being in the middle. I 
then sew a single pad on the right side of the thorax in front and a httle 
to the right side. 

The patient is now ready for the Abbott frame and is placed on a 
canvas hammock about twelve inches wide, which is cut on the bias so 
the right side is three inches shorter than the left. The hammock can be 
adjusted to the desired degree of flexion by a ratchet at the foot of the 
regular Abbott frame. The limbs of the patient should be elevated to 
increase the flexion as this has a tendency to unlock the articulation and 
thereby help in overcoming the rotation. Next a canvas bandage four in- 




patient suspended on canvas hammock in regular Abbott frame ready to apply 
cast for a right dorsal curvature. Notice manner of applying the correcting canvas 
straps. 

ches wide is passed around the patient under the axilla of the concave side 
and fastened to the frame on the opposite side, and another one is placed 
around the pelvis and fastened to the same side of the frame, both on a 
level with the body plane. A third bandage is next placed around the 
point of greatest convexity and fastened to the opposite side of the frame 
in such a way that it can be tightened and a direct pull be made on the 
curve. Before tightening the last bandage the left arm and shoulder 
should be brought up high beside the face and pulled backward toward 



776 



The Practice of Osteopathy 



the floor as it is this twisting force that produces some rotation of the 
thorax. The correcting bandage is now tightened being careful not to 
•^ause the patient too much discomfort. 

I always use ordinary absorbent cotton for padding, which is held 
in place by the regular gauze bandage. The plaster of Paris bandages 
should be applied high up under the left shoulder and well down over 
the sacrum and innominate bones and should be of a uniform thickness 
of half an inch. Sometimes I carry the plaster over the right shoulder to 
hold it down and back, though not alwaj^s. I always let the cast set 

pretty well before removing the pa- 
tient from the frame and if it has 
been applied in the morning I find it 
best to wait until afternoon before 
trimming and cutting the windows 
because there is less danger of break- 
ing it. In trimming I always smooth 
up the edges, lower the right shoul- 
der, but keep the left well up, trim 
off enough at the bottom in front to 
allow the thighs to be readily flexed 
without obstruction, and leave it low 
behind so as to maintain the flexion. 
Next, two holes or windows are cut 
in the cast, one over each area where 
the pads were inserted, and remove 
them. The hole in the back on the 
left or concave side permits expan- 
sion of the chest to the back, while 
the hole on the right side in front 
allows the ribs, which are posterior, 
to move forward under pressure or the pads to be inserted at the pos 
terior angle or backward prominence of the ribs of the convexity. Tht 
canvas bandages or straps around both the axilla and pelvis are re- 
moved, but the one about the convexity of the cm've is left in place so 
as to assist in the after treatment. The patient usually suffers some 
discomfort such as difficulty in breathing and the inability to move the 
body freely, and should remain in bed a day or two after the cast has 
been applied. Usually they sleep very poorly the first few nights, but 
the spine soon gives under the pressure and they become comfortable. 
When the cast has become quite comfortable an assistant pulls on the 




Cross section sketch of a right dorsal 
curvature showing deformity in the 
thorax and rotation of the vertebrae, 
also windows which are cut in the cast 
to allow expansion in these two direc- 
tions and the directing force of the 
pads. These are placed over the angles 
of the ribs. Arrows show directions of 
the various forces. 



The Practice of Osteopathy 777 

canvas bandage which was left around the convexity, while pads are 
inserted so that the greatest pressure is exerted on the angle of the 
ribs to further overcome the rotation and decrease the lateral deformity. 
Also heavy felt pad may be inserted over the bulging ribs in front of the 
left side to push them back. Care should be taken that too much pres- 
sure is not brought to bear on the side of the convexity because if more 
pressure is exerted here than on the angles of the ribs, it will tend to 
increase rather than decrease. 

Casts should be worn for different periods, some being changed in 
a month while others can be worn for three months. It is entirely a mat- 
ter of judgment. My best results have been secured by only slightly 
correcting the curvature at the time the cast was applied, and relying 
more on the proper insertion of the pads. Often at the end of a month 
or six weeks, in selected cases, I have split the cast down the front and 
removed it by springing it apart, and administered osteopathic manipu- 
lations to the spine freely in all dnections, thoroughly loosening up the 
muscles. Then I replace the cast and hold it together in front with mole- 
skin adhesive and insert the pads as before. I repeat this procedure 
thi'ee times per week for another month, together with daily exercises 
each morning and evening of drawing the left shoulder up and forward 
while in the cast to develop the muscles of the left shoulder girdle. The 
treatments and exercises certainly do build up the spinal muscles for it 
must be realized that they have suffered in nutrition to a great extent 
as a result of wearing the cast. Next the cast can be worn during the 
day and removed at night, and gradually it can be left off several hours 
at a time. If no bad results occur it can be left off for longer periods until 
finally its use can be discontinued. However, the patient should still 
be under observation once a week for a couple of months to determine 
any recurrence of the deformity. The resumption of active corrective 
treatment, or increasing relaxation in gymnastic work, will, of course, 
depend upon the progress of the case. 

In the more obstinate cases, casts should be applied as long as fur- 
ther correction can be obtained. The procedure is entirely the same, 
only the time required for correction is longer, sometimes a year or year 
and a half, and when over-correction has been maintained, it is better 
to use a removable jacket made of celluloid or light stiffened leather, 
with large windows cut over the region where pressure is to be avoided, 
than the removable cast described above. 

In closing let me say that this method of correcting lateral curvature 
is best adapted to patients during their growing period and though it 



778 The Practice of Osteopathy 

may be employed in older eases you will usually be disappointed in the 
final result. The only reason I can see for treating older cases is purely 
mercenar3^ 

Congenital Dislocation of the Hip 

Unilateral 

Undoubtedly as far back as 1829, the actual recognition of this con- 
dition was due to the pathological research of a French surgeon Du- 
puytren, who described this deformity with great accuracy and insisted 
that there was no possible chance of correction. From then on until 
1886 nothing was done bj^ medical science to overcome the deformity, 
though it is claimed some were made. It was in this year that the famous 
Bavarian surgeon, Hoffa, gave to the medical profession the results of 
his successful attempts at reduction by opening the hip joint from be- 
hind and enlarging the acetabulum to a size sufficient to hold the head 
of the femur. 

Orthopedic surgery has to thank the irritating effects on the skin, of 
antiseptics necessary in preparing his hands for ordinary surgery, as it 
was due to this triviality that Lorenz, a promising surgeon of Vienna, 
transferred his energies to the field of bloodless surgery and gave to us 
the most valuable early work and present day technique in the bloodless 
reduction of congenital dislocation of the hip. 

The name, of course, is applied to a congenital deformity which in- 
volves one or both hip j oints, resulting in lameness, due to a misplacement 
of the head of the femur from the acetabulum. Of all congenital dislo- 
cations the hip joint is by far the most common and most important. 
The misplacement is far more often unilateral than bilateral and far more 
frequent in females than in males, the cause for the latter probably being 
the difference which exists in aspect and position of the acetabulum as 
well as the disproportionate laxity of the capsule in the two sexes. It 
must be remembered that normally at bii'th, the acetabulum covers only 
about one-third of the head of the femur, and our most accepted theory 
as to the cause of this deformity, is a defective development of the aceta- 
bulum or its posterior margin, which may be primary or secondary to 
an abnormally prolonged fixation of the limb in a position of flexion or 
adduction while in utero. At birth it is quite probable that the disloca- 
tion is a subluxation only, which becomes complete by muscular action 
and the use of the limb in standing and walking. 

The pathology of this disease is clearly established, and varies, of 
course, with the age of the patient in strain and friction to which the 



The Practice of Osteopathy 



779 




misplaced parts have been subjected. In children over two and one- 
half years of age the acetabulum is usually shallow and small, and filled 
with a deposit of fat and fibrous tissue. It is covered with normal hya- 
line cartilage and nearly alw^ays the ligamentum teres is present, but is 
so badly stretched and ribbon-like that ultimately the artery accom- 
panying it fails to function, resulting in a malformation of the head of 
the femur. The capsular Hgament is elongated and thickened to ac- 
commodate the upper displacement of the femur, and the anterior wall 
of it is stretched tight across the acetabulum like an hour glass. The 
interior of the capsule is always partly lined with synovial membrane. 
Usually a secondary acetabulum is found upon the ileum, formed by the 
direct pressure of the head of the femur through the capsule and the re- 
sult of irritation of the periosteum of the ileum, 
but it is as a rule, not deep enough to form a 
secure support for the head of the bone. The 
neck of the femur is usually shorter than nor- 
mal and the upper extremity of the bone is 
somewhat atrophied. The pelvis is usually 
sKghtly atrophied on the affected side, and a 
lateral inclination of the spine may be present. 
The long muscles of the thigh are shortened; 
while those attached to the pelvis and tro- 
chanter are changed in direction and are usu- 
ally lengthened. 

Symptoms. — As a rule congenital disloca- 
tion of the hip is not accompanied by the defective development or 
deformity elsewhere, and the sjanptoms are so diagnostic that there is 
little difficulty in recognizing this condition even without the X-ray 
which is, of course, a positive diagnosis. 

Rarely does the displacement attract attention until the child be- 
gins to walk. Often the child does not walk as early as it should. Some- 
times it may be delayed until the eighteenth month or second year and 
then it walks with a limp which becomes more pronounced as the child 
grows older until at the fourth or fifth year it is very decided. The limp 
is peculiar and its character is explained by its cause; for the shortened 
hmb, owing to the elasticity of the capsule, becomes still shorter when the 
weight is borne upon it, thus causing a pecuHar lunge of the body to- 
wards the short side like the normal motion of walking downstairs. In 
compensation, of course, the pelvis is tilted towards the short limb and 
its inclination is thereby increased, so that the anterior superior spine 



Tjrpical congenital dis- 
location of the hip, show- 
ing the "hour glass" con- 
striction of the capsular 
ligament. 



780 



The Practice of Osteopathy 




Outline of a radiograph 
following reduction and 
removal of the first cast 
in unilateral dislocation of 
the hip. Notice the head 
in the socket and the thigh 
still flexed and abducted. 



lies at a lower level and in advance of the op- 
posite side. Usually the affected limb is about 
an inch shorter than the sound one, and in 
adult life it is considerably more. The range of 
abduction is much diminished, but flexion, ex- 
tension and adduction are quite normal, and the 
trochanter will be found elevated about an inch 
above Nelaton's line. If the thigh be flexed 
and adducted to. its extreme limit, the neck 
and head of the femur can be easily distinguish- 
ed moving under the gluteal muscles when 
the limb is rotated, or the head can usually be 
readily palpated in front when the limb is ex- 
tended. Then, too, by fixing the pelvis and 
using traction and upward pressure on the 
limb, the abnormal mobility or telescopic motion is easily demonstrated 
and this, I might add, is a very important test. 

Rarely do we find a unilateral anterior dislocation, in which the head 
of the bone lies beneath the anterior superior spine, but when this posi- 
tion is present, the sjnnptoms are much less marked than in the ordinary 
form because the relation of the pelvis to the femur is more nearly normal. 
The limp and the shortening of the limb are less noticeable because the 
tissues attached to the anterior superior spine form a relatively secure 
support. 

The X-ray, of course, makes the diagnosis 
complete. Even though the clinical diagnosis 
is certain, a radiograph is indispensible in 
every case, particularly for the purpose of 
ascertaining the exact position of the head and 
condition of the acetabulum and femur. The 
acetabulum is usually shallow and poorly de- 
veloped, more particularly the ihac portion of 
its rim. After the reduction of the dislocation, 
an X-ray picture should always be taken within 
the first few weeks, and before the plaster of 
paris cast has been removed, to ascertain 
whether the head of the femur is still in place. 
As to bilateral dislocation of the hip, the 
pathology, of course, is the same as in the unila- 
teral type. The shortening of the limbs is as a 




Outline of the same 
case following removal of 
the second cast. The head 
of the femur is firmly fixed 
in the acetabulum and 
the position of the limb is 
nearlv normal. 



The Practice of Osteopathy 781 

rule equal or nearly so, and when both femurs are displaced backward, 
the pelvis is tilted forward thus presenting a marked lumbar lordosis 
and protruding abdomen. The pelvis seems to be abnormally wide, 
both buttocks are flattened and the thighs are separated by a consider- 
able space. The characteristic hmp in this condition is an exaggerated 
waddle, often spoken of as "sailor gait." Again in this condition rarely 
do we find an anterior dislocation, but when such is the case, the entire 
body is swayed entirely backward, though the lumbar lordosis is not 
increased, in fact usually presents a peculiarly flattened appearance. 
Other symptoms differ only in a slight degree from those of the ordinary 
posterior displacement. The physical signs are the same as the uni- 
lateral displacement and are even more readily recognized by the peculiar 
appearance and distinctive gait of the patient. The swaggering gait of 
himbar Pott's Disease is somewhat similar, but this is an acquired clin- 
ical condition of the spine in which the hip joints are normal in appear- 
ance and nearty so in function. 

Before taking up the usual procedure for the correction of congenital 
dislocation of the hip, it might be interesting to touch on several cases 
of this deformity in young children that I have reduced without an an- 
esthetic. If future experience proves as successful as these cases it will 
entirely revolutionize the treatment of this condition especially in chil- 
dren under twenty months of age. To begin with, these children had just 
started to walk and it must be remembered that at this stage the aceta- 
bula are nearly normal and there has been no muscular or ligamentous 
contraction because very Uttle weight has been borne on the limb. 

First the pelvis is held fixed by the assistant, and the thighs com- 
pletely flexed on the abdomen. Next firm pressure is made on the knee 
to force the head of the femur beneath the acetabulum and as the Hmb 
is abducted in the flexed position, the head is raised into the acetabulum 
with the thumb of the operator's other hand. The whole procedure takes 
but a moment's time and the child should be placed at once upon the 
floor and allowed to walk. Time will tell if the reduction has been suc- 
cessful, and if failure of retention develops, the Lorenz method followed 
by plaster of Paris fixation can still be used. I should always recom- 
mend the trial of this method in children who have walked not longer 
than six months, before resorting to the following Lorenz treatment. 

Treatment by the Lorenz Operation. — This treatment is based 
on the fact that there is normally present an acetabulum of sufficient 
size and capacity to retain the head of the femur, providing the limb 
can be fixed in a favorable attitude, and as soon as possible weight borne 



782 The Practice of Osteopathy 

upon it to deepen the rudimentary acetabulum. The typical operation 
of today is best divided into fom- distinct steps; first, to overcome the 
resistance of the tissues surrounding the joint; second, to reduce the dis- 
location, or rather to force the head of the femur over the posterior bor- 
der of the acetabulum; third, to inci-ease the security of the articulation 
by stretching the anterior border of the capsule; fourth, to fix the parts 
in a plaster of Paris bandage. 

The child is completely anesthetized, and an assistant firmly fixes 
the pelvis on the table with his hand. The operator first flexes the thigh 
to a right angle with the bodj^ and forcibly abducts, at the same time 
kneading and stretching the tense adductor muscles and if necessary rup- 
turing the adductor tendons in order to bring the limb down to the plane 
with the body. Next to overcome the contraction of the posterior tis- 
sues, the limb fully extended is flexed upon the trunk and gradually 
forced downward until the toes touch the patient's face. To overcome 
the resistance of the tissues on the front of the joint, it is best to move 
the patient to the edge of the table and forcibly extend the thigh down- 
ward behind the plane of the body. It is also well to apply direct trac- 
tion in the line of the body. This preliminary stretching is absolutely 
necessary, because all the tissues about the joint are so shortened, and 
it will now be noted that with slight traction the trochanter can be drawn 
down to Nelaton's line. 

Next reduction is attempted by grasping the limb with one hand at 
the knee and strongly abducting it while the palm of the other hand is 
placed on the anterior spine of the ihum with the thumb placed beneath 
the great trochanter to act as fulcrum. As the limb is gradually forced 
downward to and behind the body plane, the head of the femur is forced 
upward until it finally slips over the posterior and inferior border of the 
acetabulum. In the more resistant cases a padded wedge-shaped block 
placed behind the trochanter will be an aid in pushing the head for- 
ward and upward while the patient's knee is forced downward. A suc- 
cessful reduction is usually accompanied by a distinct jar and audible 
thud, and it would be observed that the tension upon the ham string 
muscles causes fixed flexion of the leg. After reduction has been made, 
the limb should be brought down carefully into a straight position to 
test the security of the re-position. If dislocation appears during this 
manipulation, the tissues must be still fm'ther stretched and the dis- 
placement further reduced. If displacement occurs readily due to a 
shallowness of the acetabulum the prognosis is not so good as where 
the stability remains when the limb is brought down into a straight 



The Practice of Osteopathy 



783 




Patient in position for 
the first cast in a left uni- 
lateral dislocation. The 
thigh should be a little 
past a right angle in rela- 
tion to the trunk, with 
about 80° abduction. 



position, and one must be more particular in 
the fixation of it. I have also observed that 
the more difficult the reduction the more stable 
the end results. The easy replacements are 
usually just as easily displaced. Sometimes the 
head slips into the socket quietly without the 
distinct jar or thud but the results in these 
cases are just as good provided they are pro- 
perly cast. 

The application of the plaster spica is by 
far the most important part of the treatment, 
as the reduction is usually quite easily accom- 
pHshed in children under six years of age. If 
the cast is improperly apphed, the hip will sUp out of the socket and the 
case is a failure. A pair of soft knitted cotton drawers are put on and 
the patient is placed upon a pelvic rest with the limb held in the position 
of greatest stability at a right angle with the trunk, or even slightly 
more and about eighty degrees abduction. In a case where the socket 
is very shallow, the position to be cast should be about one hundred de- 
grees flexion, and in abduction the hmb should lie sHghtly behind the 
plane of the body to secure the best results. 

The limb and pelvis are covered with ordinary absorbent cotton 
which is held in place with a roller gauze bandage. A snug fitting plaster 
of Paris cast is now applied around the pelvis and well down over the 
knee. I leave this over the knee for five or six days or until the child 
ceases to be fretful, then I cut it away just back of the knee joint to per- 
mit motion there. The ends of the drawers are drawn back smoothly 
over the cast and are sewed to each other. For about a week following the 
operation the adductor regi3n is swollen and discolored and more or less 
painful due to rupturing and stretching of those tendons. After this 
discomfort has passed away, walking is encour- 
aged on the theory that the weight bearing and 
the stimulation of functional activity will in- 
crease the stability of the joint by deepening 
the acetabulum. 

The first cast should remain from three to 
six months according to the stability of the 
joint at the time of reduction. If in young 
children the cast becomes offensive, it must 
be changed as often as is necessary. When 




Correct position and 
proper application of cast 
for double congenital dis- 
location of the hips. 



784 



The Practice of Osteopathy 




Proper position of the limb 
in the second cast for unilat- 
eral dislocation. 



the first cast is removed, the hmb is pulled 
down to about thirty degi'ees abduction and 
the same amount of flexion, without an an- 
esthetic, and a second cast is applied, which 
extends only to the knee, to be worn from 
three to six months longer. After removal 
of second cast, the child is permitted to get 
about carefully. The limb will be everted 
and slightl}^ flexed, which position invariably 
causes much concern among the relatives 
of the patient, but this abnormal condition 
disappears after a few months' time. Some- 
times for even a year following removal 
of the second cast there will also be a no- 
ticeable hitch in the walk of the child, but 
this, too, disappears and in the course of 
two years' time one could never tell that 
such an operation had been performed. 
Massage of the posterior and lateral mus- 
cles of the hip always helps considerably towards the relief of any 
stiffness or lameness. 

Reduction by Open Incision 

In the more resistant older cases, where manipulative reduction 
has failed, reduction by incision can be employed with success, but this 
procedure requires the exercise of care in order to do as little injury to 
the muscles as possible. A crucial incision of the capsule is made and 
the capsular constriction and ilio-psoas tendon divided. With a little 
traction, the head of the femur slips easily into its socket. The capsule 
is stretched firmly around the neck and the incision into the capsule 
is then closed by suture, and the limb fixed in a plaster of Paris spica 
in the fully abducted position. The operation should of course be done 
under the strictest asepsis. 

Talipes or Club Foot 

The word talipes signifies some deformity of the foot and is quite 
common in orthopedic practice, being found in nearly ten per cent of 
the cases coming under this branch of the science. Club foot may be 
classified into two types — the congenital and the acquu'ed. The congen- 
ital type is the most common and is due probably to abnormal intrauter- 
ine pressure or to a perversion of normal intrauterine development. 



The Practice of Osteopathy 



785 



The acquired type is due usually to injury or infantile paralysis, but 
either joint disease or cerebral paralysis may be the cause. The de- 
formity presents six different forms with most characteristic chnical 
pictures which, with the exception of talipes planus I have taken up in 
the order of frequency. 

Talipes Equino varus is usually congenital and is the most com- 
mon type. It is characterized by inversion and torsion of the foot with 
elevation of the heel. The weight is borne on the outer side of the foot 
and in extreme cases upon the dorsum as well. Calluses are always 
present which are red and painful upon the point where the greatest 




Illustrating the more common types of talipes. A combination of any may be 
present. 

weight is borne. The most common method of treating this condition 
is to divide the tendo Achilles at a level with ths malleoli. The oper- 
ation should be done aseptically and under complete anesthesia. As 
an assistant raises the end of the foot so as to stretch the tendo Achil- 
les the surgeon enters the knife parallel to the border of the tendon through 
the skin and tendon sheath into the tendon itself. Next with a tenotome 
inserted into the incision and turned at right angles to the tendon, the 
tendon is divided fii'st on one half then on the other. Care should be tak- 
en to disturb the tendon sheath as little as possible for it serves an im- 
portant purpose in repair. When the division is complete as indicated 
by the separation of the divided ends, the tenotome is withdrawn and 
tlu! luinuto opoiiinK in the skin, from which 1here is only slight bleeding. 



786 The Practice of Osteopathy 

is covered with aseptic gauze. The foot is forced into dorsal flexion and 
if in severe cases the deformity is not then corrected, the tendons on the 
outer side of the foot may be shortened, while those on the inner side may 
be lengthened in the same manner as the tendo Achilles. A plaster of 
Paris cast is then apphed well up to the knee with the foot in the over 
corrected position, care being taken that no undue pressure is brought 
upon the seat of operation^ as this might interfere with the effusion of 
plastic material. Personally I believe that functional use of the limb 
and foot stimulate repair, and I always encourage the patient to stand 
and walk after the discomfort of the operation has passed. At the end 
of four weeks the space between the two cut ends will be filled with new 
material and the cast can be removed, and in another month the splice, 
which is somewhat larger and thicker than normal, should be strong 
enough for use. In the course of a year the lengthened tendon is per- 
fectly normal. 

Talipes Equinus. — ^In this type the patient walks on his toes with 
the heel highly elevated, in the same position as the horse, and it will be 
noticed that the foot has no dorsal flexion whatsoever. Infantile paral- 
ysis affecting the anterior muscles of the leg is usually the cause of this 
condition, though sometimes shortening of the leg following knee joint 
disease, or fracture may lead to an adaptive equinus which serves to 
make the limb of equal length for walking. This type is by far the 
easiest to remedy, and the results following operations are perfect. A 
simple division of the tendo Achilles is made under anesthesia and a 
cast applied as above, in a position of exaggerated dorsal flexion. Func- 
tional use of the limb after the cast has been removed overcomes any 
stiffness that might occur and perfect results are obtained in a short 
time, compared with the other types. 

Talipes Caleaneous. — This is a condition in which the foot is held 
in a position of dorsal flexion. The patient walks on the heel with an 
inelastic gait because the spring of the foot is absent and the whole 
weight is borne upon the os calcis. The best procedure in this type is 
manipulative treatment into a position of plantar flexion to overcome 
the contraction of the anterior muscles of the foot and leg, and bring 
about contraction and shortening of the posterior muscles. A tenotomy 
of the anterior tendons or an anesthetic is rarely indicated, though in 
severe cases, a series of casts holding the foot in position of plantar flexion 
may be necessary to secure good results. I have found it a help to have 
a shoe with a heel prolongated backward, or a steel splint laced to the 
leg to prevent the foot from upward motion. 



The Practice of Osteopathy 787 

Talipes Valgus. — This is a very uncommon type of deformity, 
characterized by eversion of the foot. The patient walks on the inside 
of the foot and, as a rule, experiences very little trouble. I find a ma- 
nipulative treatment is best for this condition, aided by braces. 

Talipes Cavus. — This form is sometimes called "hollow foot" 
and is very uncommon in this country. It is characterized by a marked- 
1}^ high arch sometimes as in Chinese women to the extent that the anter- 
ior part of the foot is approximated to the heel. The plantar fascia is 
badly contracted and one can distinctly palpate the bands beneath the 
skin. This condition is practically the same as the ordinary so-called 
•'contracted foot" except that it is much more exaggerated. The 
ordinary high arch of today is usually the result of wearing too short 
a shoe, and if painful, long last shoes, aided by manipulations, will usually 
correct the trouble. In severe cases of contracted foot the plantar fascia 
may be divided, under anesthesia and the arch brought down and put 
in a cast, though this procedure is not very successful. In case it is done 
the patient should be made to walk in two or three weeks, as this helps 
materially to overcome the deformity and hasten repair of the fascia. 

Talipes Planus. — This condition is commonly known as "flat 
foot" and is taken up in another part of this text. However, it is one of 
the classifications of "club foot" and is far the most common type. 

Prognosis. — These conditions never correct themselves and if 
uncorrected usually get worse and the more severe types certainly become 
obstinate malformations. In general the tendency to relapse is strong, 
though if properly treated the results are excellent. In infantile cases 
the time required for correction is relatively short, but retentive appli- 
ances are needed for a longer time. The older the cases and larger the 
foot the more difficult, of course, the correction, but usually there is 
less danger of relapse. A perfect correction, that is when the gait and 
attitude are normal, will never relapse. I find it better to leave the fixa- 
tion appliance on too long than not long enough. Never remove a cast 
under four weeks except in the cavus type, then apply a brace such as 
can be obtained from any supply house for any type of case, for from 
one to three months longer. The tendons involved in these conditions 
are so apparent that it is almost impossible to make a mistake in the 
division of them. About the only precaution necessary is to be assured 
that the tendon itself is completely divided, but that the tendon sheath 
is only slightly disturbed. 



788 The Practice of Osteopathy 

Tuberculous Disease of the Bones and Joints 

Perhaps no bony lesion has caused so much difference of opinion 
in this profession as tubercular conditions of the spine, bones and joints 
and I wish it understood that in the following discussion, it is not mj' 
desire to reopen the argument. My observations have been of cases 
treated both osteopathically and by fixation, in private practice and 
institutional work. And I have come to the conclusion that the fixa- 
tion method of treatment is absolutely always indicated. In general 
the pathology and etiology of all tubercular bone conditions is the same. 
It begins as a tubercular infection of the spongy tissue of the epiphysis, 
the first change being a local hyperemia of the portion involved, followed 
by one of thi'ee courses : the diseased focus being absorbed and a sponta- 
neous cure resulting; it may extend to the periphery of the bone and break 
through the periositum and empty itself there by abscess formation; 
or most commonl}^ it may extend to the joint, which becomes involved 
through attendant injury-. Repair is brought about by the formation 
of fibrous tissue probably arising from the layer of non-tuberculus gran- 
ulation tissue which grows in and replaces the tuberculous tissue. Also 
the replacing material may become calcified and encapsulated. A fi- 
brous or bony ankjdosis may result from this process of repair. 

The vulnerabiUty of growing bone accounts for the frequency of 
tubercular bone disease in cliildren as compared with adult life. Injury 
not only causes a local predisposition to the disease, but it favors its pro- 
gress when it is once estabhshed. About seven-eighths of the cases of 
this trouble occur under fourteen years of age, more especially when the 
vertebrae or liip-joint are involved. The knee and anlde joints as well as 
the elbow and shoulder joints are more often diseased in later fife. While 
the inherited predisposition is very direct and positive in twenty-five 
percent of the cases, the acquired predisposition is of most importance 
since it includes lessened vitality due to poor food and imperfect hygienic 
surroundings. As to the distribution of the disease the vertebrae are 
most commonly affected, followed closely by the hip and knee joints, and 
then in the order of frequency the ankle, elbow, shoulder and wrist joints. 

Tubercular Disease of the Spine 

This condition is commonly called Pott's Disease or Caries. It 

is a chronic destructive process of the bodies of the vertebrae. The 
spine bends at the weakest point and the compression and collapse of the 
affected parts cause the characteristic posterior angular projection at 
the seat of the disease. If one vertebral body is destroj^ed, the projec- 



The Practice of Osteopathy 789 

tion will be sharp; ix several are involved it will be less angular and if 
one side breaks down before the other, there may be a lateral as well as 
posterior distortion. The size of the deformity and its effect upon the 
patient depend upon its situation; that is, if either end of the spine is 
involved the angular projection is sHght because the area of the spine di- 
rectly involved in the deformity is small compared with that which is free 
from the disease. If the middle of the spine is affected, the deformity 
is great, because the entire spinal column may enter into the angular 
projection. In the latter area the internal organs are compressed and, 
of course, the effect upon the vital organisms of the body is disastrous. 

Pathology. — The first indication of tubercular disease of the spine 
is usually found in the anterior part of a vertebral body just beneath 
the fibro-periosteal layer of the anterior longitudinal hgament. From 
this point the foci may advance along the front of the spine following 
the course of the blood vessels and invading the adjacent vertebral bodies. 
The destruction may begin in the interior of the body itself, more often 
in several minute foci near the upper or lower epiphysis, which coalesce 
gradually enlarge and form a cavity surrounded, for a time, by unbroken 
cortical substances which finally collapse under the pressure of the weight 
above. The intervertebral discs seem to offer some resistance to the 
extension of the disease from one vertebra to another but once the bone 
is destroyed on either side, they too quickly disintegrate and disappear. 
Pedicles and articulations which come into direct contact with the disease 
may become involved. Originally the disease is confined to one or two 
adjacent vertebrae and may extend in either direction, and the final 
area of deformity and rigidity shows that from three to six bodies may 
be involved before a cure is estabUshed. The infected granulations ad- 
vance rapidly with the usual retrograde change of shape and structure 
to a cheesy degeneration and frequently liquifaction and abscess forma- 
tion may follow. 

Symptoms of Pott's Disease. — There are three main symptoms 
of Pott's disease, namely the peculiarity of attitude and gait, limitation 
of motion or muscular stiffness and the pain and referred pains. In 
the cervical region, the chin is held somewhat raised and the patient 
may have somewhat the same appearance as in wry-neck. In the mid- 
dorsal region one will always find an elevation of the shoulder besides 
the deformity. In the lumbar region, the patient nearly always leans 
})ackward and has a sort of sidling gait or waddle due to the contraction 
of the psoas and iliacus muscles. The patient in walking, stooping, or 
lying down most carefully guards the spine against any jar or motion, 



790 The Practice of Osteopathy 

and always assumes attitudes which will relieve the strain on the in- 
volved vertebrae. There is always present an unnatural mode of stand- 
ing or walking, especially when the dorsal and lumbar regions are in- 
volved, as the patient walks more on his toes and with the knees slightly 
bent, because in this posture all possible strain of the step may be brought 
into play to diminish jarring of the spine. The child becomes tired 
very easily and hes down or rests on the arms of a chair or seat. The 
pain rarely occurs in the back, but is usually referred to the peripheral 
end of the nerves and is thus felt in the chest, abdomen or limbs. The 
abdominal pain passes sometimes as a stomach ache and often times in 
the Kmbs, as rheumatism or "growing pains". I have noticed ako a 
peculiar grunting respiration and sometimes cough especially when the 
mid-dorsal region is involved. Muscular stiffness is always present, all 
mobihty being lost. The temperature is not at all diagnostic, though 
sometines in the afternoon it will be one or two degrees higher than 
normal and does occur independently of abscesses. About the only com- 
plication that occurs is paralysis or abscess formations. Paralysis is 
given as a frequent compUcation, though I have never seen it. It is us- 
ually flacid and bilateral and may exist from a mere muscular weakness 
to a complete loss of power. It is certainly uncommon under proper 
treatment, and the prognosis is favorable. Abscesses, though a very 
distressing compUcation, are very uncommon in my experience and are 
certainly an evidence of improper or incomplete treatment. They may 
subside in any region and be absorbed without detriment to the patient, 
though if they increase in size there is no tendency towards absorption. 
It is best to incise them and secure complete drainage. It is hard, of 
course, to do this on account of the depth. Abscesses occur always in 
close proximity to the disease. 

Treatment. — Some authors recommend a brace for the treatment 
of this condition, while others recommend a frame to which the patient 
is strapped, and rest in bed. I have found nothing that gets results 
like a plaster of Paris jacket apphed with the patient suspended by 
the neck and shoulders. I make no attempt at correction of the de- 
formity present other than the traction of the weight of the body at 
the time the cast is applied. The spine is, of course, fully extended 
by this and any undue pressure on the cord reheved. The cast should 
extend over the shoulders and well down over the pelvis and sacrum. 
If the disease is in the neck the cast should include the head as well. 
A large window is cut in front and one must be cut over the invoved 
area of the spine behind. Ordinary absorbent cotton is used for pad- 



The Practice of Osteopathy 791 

ding with, of course, extra padding over all bony prominences. From 
two to five years' time is required for a complete recovery. The X-ray 
is invaluable in diagnosing this trouble, and each time a cast is removed 
to see how much progress has been made. The casts should be changed 
as often as they become soiled. 

Tuberculosis of the Hip 

This is a chronic tubercular condition of the head of the femur or 
of the acetabulum commonly known as hip-Joint disease. 

Pathology. — Primarily the head of the femur is the seat of the 
disease, the epiphysis being attacked in seventy-five per cent of the 
cases and the acetabulum in twenty-five per cent. The irritated pel- 
vic femoral muscles which are in a state of chronic contraction crowd 
the head of the femur against the upper and back border of the aceta- 
bulum. Under this continual pressure, absorption of that portion of 
the rim takes place with actual enlargement of the acetabulum from 
below upwards. This is spoken of "migration of the acetabulum" 
and is one cause for the shortening of the limb. Changes in the head 
of the femur are the result of inflammation and pressure. Partial de- 
struction of the head also helps shortening of the hmb and elevation of 
the trochanter above its proper level the same as the wearing away of the 
acetabulum. The synovial membrane is found to be reddened and 
thickened and granulation tissue is present, and usually the cartilage is 
gone from the head of the femur. Rarely does perforation of the floor 
of the acetabulum take place, but if such is the case a dense wall of fibrous 
tissue and thickened periosteum shuts off the head of the femur from the 
pelvic cavity. A natural cure results in two ways, — by absorption or 
calcification of the tubercular tissue, or by the evacuation and discharge 
by an external opening. This latter suppuration seems to be nature's 
effort to eUminate the disease, and when a cure is estabhshed this way it 
is usually characterized by mal-positions and shortening of the hmb, 
and, of course, an ankylosed joint. 

Early Symptoms. — The most characteristic symptoms of the 
disease are the 'night cries', stiffness and hmping, shortening of the leg, 
atrophy of the muscles of the hip, leg, and thigh, and the unconscious 
protection of the joint. A referred pain is usually present to the inside 
and front of the thigh near the knee or directly at the knee joint itself, 
due to the intimate relations and anastamosis of sciatic, obturator, and 
anterior crural nerves. 

Diagnosis. — The chief diagnostic sign is muscular spasms or the 



792 The Practice of Osteopathy 

presence of stiffness of the joints and limitations of its proper arc of mo- 
tion, due to the tonic contraction of the muscles controlhng the joint. 
If there is no limitation of motion it is almost safe to say there is no 
hip-joint disease. The lameness may be intermittent. The attitudes 
or abnormal positions of the diseased limb are caused by the action of 
muscles holding the hmb stiffly in a distorted position. The pelvis is 
usually tilted and always one will find the patient assuming attitudes 
which will favor the diseased limb. Atrophy is very significant and a 
comparison of the two limbs should be made by measuring at the middle 
of the thigh and the middle of the calf. Nearly always one will find a 
deep thickening over the front of the hip joint and behind the trochanter. 

Physical Examination. — 1. Observe the general condition of 
the patient. 

2. Note the attitude in standing. 

.3. Note character of the limp. 

4. Note shortening of the hmb. 

5. Remove the clothing and lay patient on the back. 

6. Test the function of the groin. Always begin on the sound side 
for comparison in order that the patient may become accustomed to the 
manipulation before the hmb suspected of disease is tested. Tuber- 
culosis in a joint is always accompanied by muscular spasms that pos- 
itively Hmit motion in every direction, while in other affections only 
one or more hmitations are observed, but never in all directions. Com- 
pare closely the motions of the sound and affected hmbs while the pa- 
tient is on the back. Turn patient on face and test for extension by hold- 
ing pelvis flat on table with one hand and gently elevating thigh with the 
other. The normal range in a child is about twenty degrees backward 
from the Hne of the body and Hmitation of this range is perhaps the earli- 
est indication of hip-joint disease. It is due to psoas contraction. If 
this range of motion is unrestricted hip disease can be practically ex- 
cluded. 

The X-ray completes the diagnosis when used with a thorough 
knowledge of the physical signs. It must be remembered that in early 
life a larger part of the extremity of the femur is cartilaginous and does 
not show. well in a radiograph. The X-ray picture shows clearly the 
destructive effect of the disease on the femur and acetabulum and gives 
a clear conception of the actual condition of the joint. 

Treatment. — The object of treatment of this condition is three- 
fold: first, to reheve the pain that depresses the vitality of the patient; 
second, to relieve the muscular spasms that induce distortion of the limb 



The Practice of Osteopathy 793 

and which stimulates the destructive process by increasing pressure and 
friction of the diseased surfaces of the opposing bones; third, to correct 
and prevent deformity by lessening pressure and by restraining motion, 
thereby keeping the femur from upward displacement. 

Rest and protection are the two cardinal features of treatment of 
this condition. Sunshine, fresh air and good nutritious diet are very im- 
portant. 

Complete rest of the joint offers the most favorable opportunity 
for nature to repair this disease. The recumbent period of the treat- 
ment necessitates rest in bed for the reduction of the deformity and sub- 
sidence of acute symptoms. By the aid of traction, which is applied to 
the length of the legs by means of a Buck's extension. As much weight 
should be applied as can be borne without discomfort to the patient. 
As soon as the deformity and acute symptoms have subsided, the 
ambulatory treatment should be substituted to keep up the general 
health of the patient. This merely consists of the appHcation of a long 
plaster of Paris spica of the hip which should reach well up to the thorax 
and extend down and include the foot. All bony prominences should 
be well padded, and a moderate amount of traction with about twenty 
degrees al)duction should be used while applying the plaster bandage. 
Though various forms of apparatus have been devised for fixation and 
traction, I believe that the plaster of Paris spica is far the most effective 
and should always be used, changing the cast as often as it becomes 
soiled. Locomotion is possible with crutches providing the shoe on the 
well side is stilted by an iron patten which is high enough to allow the 
casted Hmb.to clear the floor. 

The earlier treatment is begun, the better the outlook. Recov- 
ery with perfect motion occurs in about twenty-five percent of hospital 
cases; fifty per cent will obtain useful motion and the other twenty-five 
per cent will obtain practical fixation, but it must be remembered that 
results will range entirely according to the thoroughness of treatment, 
the severity of the disease in the individual case, and the natural resist- 
ance of the child. In general, the hip should be fixed as long as it is 
sensitive, it should be protected and distracted as long as there is mus- 
cular spasm, and protected until the congested and inflamed bone of the 
epiphysis is replaced by firm healthy bone. 

Tuberculosis of the Knee Joint 

Tuberculous disease of the knee is next to the hip in frequency. 
It is a chronic destructive process of the epiphysis of the femur or tibia, or 



794 The Practice of Osteopathy 

it may start in the patella, head of the fibula, or primarily in the synovial 
membrane of the knee joint. The condition presents two distinct types; 
one, the adult type beginning as a chronic synovitis, of which the early 
symptoms are subacute; and the other, the childhood or most common 
class, in which the symptoms of pain, muscular spasms and deformity 
seem to indicate clearly a primary disease of the bone. 

Symptoms. — This disease is commonly known as "white swelling" 
and the symptoms as a rule are ouite characteristic. The affection be- 
gins with a limp and limitation of motion, and is usually slow in pro- 
gress with periods of severe pain. There is usually much swelling and 
this together with the distortion of the limb by muscular spasm and 
atrophy of the muscles both above and below the joint, gives a most 
characteristic knock-kneed appearance. The affected limb is usually 
longer at first, owing to the congestion of the epiphesis of the knee. Local 
heat is always present in the more acute stages and the lameness is usually 
a constant SAmiptom. The differential diagnosis from other joint troubles 
is easy because of the slow insidious onset. 

Treatment. — Like other tubercular bone conditions the fixation 
treatment is best. Rest in bed with a Buck's extension to overcome the 
deformity and the local application of hot packs until the acute symp- 
toms have subsided, is the best preliminary treatment of this condition. 
Five- to ten-second exposures to the X-ray each day for ten days seems to 
relieve the pain and in most instances causes less marked infiltration of 
tissues. 

When the acute stage has subsided, the ambulatory treatment by 
fixation in a plaster of Paris cast extending from the groin to the ankle^ 
with about 10 degrees flexion, is most efficient. 

The patient is allowed to walk about with the aid of crutches, having 
the shoe on the sound side stilted enough so that the diseased limb clears 
the floor. The functional results after conservative treatment are in 
the average case excellent, that is providing proper treatment is begun 
at an early stage. Useful motion is obtained in fifty per cent of these 
cases, perfect motion is restored in twenty-five per cent, and complete 
rigidity results in the other twenty-five per cent of cases. 

Any chronic, painful inflammation confined to a single joint, in 
which motion is limited by muscular spasm, and in which there is a ten- 
dency towards deformity, is almost always tubercular in character. 



The Practice of Osteopathy 795 

The Plaster of Paris Bandage 

The plaster of Paris bandage was perhaps first applied by Kluge of 
Berlin in 1829, but to the Dutch physicians Mathysen and Vander Loo 
belongs the credit of the modern bandage. 

It is imperative to give, in this chapter, a detailed and complete 
description of what constitutes a properly made plaster of Paris bandage 
and the application of it, in order that the general practitioner may be- 
come familiar with its use. Even though one cares not to treat the 
conditions heretofore enumerated, I have found that for fractures of 
almost every bone in the body requiring immobilization, the plaster 
bandage property applied is far superior and rather to be preferred to 
any other form of splints. 

It has been used very Kttle in the past in private practice because 
the ordinary commercial bandage found in any supply house does not 
come up to requirements, in that it is usually air slaked or the plaster 
has been shaken from it by the time it is received. Then too the mesh 
is too closely woven and the plaster lies on the bandage instead of in the 
meshes and there is, in consequence, an excess of plaster; also as a rule 
the bandages are rolled so tightly that the water does not reach the 
deeper laj^ers. 

The ordinary plaster of Paris bandage made in your own office can 
always be successfully applied because the right quantity of plaster can 
be incorporated in the bandage and it can readily be made into the de- 
sired widths. The plaster of Paris to be used should be of the superior 
quality used by dentists and should be of the quick setting kind. It 
<?an be procured at almost any drug store but the surest place for qual- 
ity will be your dentist. 

Absolutely, the only kind of gauze to be successfully used is white 
crinoline of the ordinarj' variety used by dressmakers and obtainable 
at any dry goods store in twenty-four yard bolts. It is especially de- 
sirable to get a kind not too rich in starch or dextrin and of a mesh run- 
ning about one hundred holes to the square inch. 

The bandages should be made in six yard lengths, and of widths 
ranging from three to five inches according to the part that is to be cast ; 
for instance the three inch widths are most suitable for casts for the ex- 
tremities, while the larger ones serve best for conditions of the spine. 
After the length had been measured and cut the desired widths can be 
torn the full length without trouble. The edge of the crinoline nearly 
always frays out and natui-ally will become so entangled as to prevent 



796 The Practice of Osteopathy 

rolling in the plaster or as to hinder the free unrolling of the bandage 
when applying it. To prevent this, three threads shovild be plucked 
from each side of each strip before starting to roll in the plaster. 

A hard surface of, at least, two feet in width should be used on which 
to roll in the plaster. Starting at one end, a handful of plaster of Paris 
is rubbed into the crinoline with the palmar surface of the hand, bearing 
down hard, so that all excessive plaster passes to either edge of the band- 
age. No more plaster should be rubbed into the crinoHne than the 
meshes will hold, and as each successive yard is incorporated with the 
necessary amount of plaster, it is loosely rolled in such manner that in the 
center of the bandage there is a hollow cylinder of the thickness of the 
index finger, and the concentric layers are easily movable on one an- 
other. This manner of rolling permits of the rapid and uniform spread 
of water through the bandage when it is to be applied, and prevents 
parts of the bandage from being insufficiently moistened. 

The general practitioner should always keep on hand about ^ 
dozen completed bandages that he is most accustomed to using in lii- 
daily practice. These should be corded as it were, to prevent unrolling, 
in an air tight container, either of glass or tin in the bottom of which is 
placed a small quantity of plaster of Paris, and should always be kept in 
a dry place. I have never found either a nm'se or an office girl who could 
not make these bandages successfully so that in the future there is no ex- 
cuse for a practitioner not using this superior form of splints. 

The Immediate Use of the Bandage 

While plaster of Paris is in no way harmful to either garments or 
surroundings, both the operator and the assistants should be properly 
gowned and the floor covered with newspapers to prevent unnecessary 
soiling. It should be borne in mind that if a properly made bandage is 
used, which is squeezed to the extent of ridding it of an excess of water, 
very few drippings will be scattered and the whole procedure of the 
application of the plaster differs in no way from simple roller bandaging. 

The number of bandages intended for use should be taken from the 
container and placed in a pan near the pail holding the water, in which 
the3^ are to be immersed, in a position in relation to the pail that will 
guard against water being splashed upon the dry bandages, which would 
render them unfit for subsequent use. Water as hot as the hand will 
tolerate, as opposed to cold, facihtates setting. I do not recommend any 
chemicals to hasten setting, because a properly made bandage, prepared 
as above, of quick setting plaster sets in remarkably fast time. 



The Practice of Osteopathy 797 

The area to be cast should be encased in ordinary absorbent cotton 
of the thickness in which it comes rolled, putting an extra pad over all 
marked bony prominences, and a roller gauze bandage applied to hold it 
in place and snug to the part. Under no consideration do I advise the 
use of flannel bandage or the ordinary sheet wadding cotton that are 
recommended by some authors, because padding with these materials is 
always conducive to applying a cast far too tightly, especially in fractm-es 
where the swelHng increases after application thereby causing constric- 
tion of the hmb and interference with circulation. The regular absorb- 
ent cotton as padding beneath a cast is always best for it is almost im- 
possible to apply a cast too tightly when it is used. 

The bandage should be completely submerged on its side, and should 
remain so until the bubbles cease to come off, which time takes place 
most readily in the properly rolled dressing. When the bubbUng has 
ceased, the bandage is Hfted out of the pail and squeezed with the hands 
merely to free it of the excessive water, the end is found and handed to 
the operator ready to apply. No undue traction should be made in 
applying the successive turns of the bandage, though it must be remem- 
bered the cast should fit snugly to the part, and the ordinary rules of 
simple roller bandaging followed, except that the reverse spirals are un- 
necessary. The assistant should constantly rub the layers as they are 
applied by the operator, as this not only helps the cast to fit more snug- 
ly, but also makes the rough edges of the bandage adhere more firmly to 
the layer beneath, thereby making a smoother cast. 

As a rule there need be no dread of an increased swelHng beneath 
the bandage because usually several hours have elapsed after the injury 
before the physician has arrived and made preparations to apply the 
plaster. Indeed, one of the best means of hmiting swelhng after a frac- 
ture is the prompt application of a plaster of Paris bandage. If there 
is any concern that the cast is too tight, while the plaster is still soft it 
can be easily cut through the entire length with a knife, and thus relieve 
the pressure existing. Also it is a good plan to cut a window or opening 
over the sight of injury, which would in no way harm the object of the 
cast and would allow a gentle massage to the part. A neat finish may be 
given to the edges of a plaster cast by turning over the ends of the cot- 
ton, in cuff-like fashion and held in the grasp of the last few turns of the 
plaster at cither end. 

On clothing you will find it best to allow the plaster to dry before 
removing, while on furniture or the hands it is readily removed by wash- 
ing off in warm water. The water in which the bandages were immersed 



798 The Practice of Osteopathy 

contains, of course, considerable plaster, and under no circumstances 
should this be emptied into a sink or waste pipe for it will certainly de- 
mand the services of a plumber. The water may be poured out on the 
ground and the paste shaken into a refuse barrel or ash pile. The best 
way to remove a cast is to moisten it with water or vinegar along the path 
of the knife. I might add that all patients are in constant fear of being 
cut either while you are trimming, cutting windows, or removing the 
cast, but because of the cotton padding underneath you will find that 
it is almost an impossibiHty. Care, of course, should be taken that the 
knife does not shp in any of these procedures and come in contact with 
the unprotected parts. 

In general, for fractm'es of the extremities it is best to apply the 
plaster with the patient in the recumbent position to secure complete 
muscular relaxation, and the part to be cast should be supported by an 
assistant. It is also a general rule that in fractures of the shaft of the 
long bones, especially of the lower extremities, the plaster bandage should 
be applied to include the adjacent articulation and extend well beyond 
the joints. 



INDEX 



Abbott treatment, 98, 774, 778. 
Abdomen pendulous, 127. 
Abdominal examination, 51. 
rheumatism, 466, 467. 
technic, 77, 536, 539. 
dangers of, 87, 540. 
Abducens nerve, lesions affect- 
ing, 717. 
Abscess of rectum, 174. 

perinephritic, differentiate pye- 
litis, 628. 
peritonsillar, 278. 
Achylia gastrica, differential diag- 
nosis, 508. 
Acne, 150. 

Accommodation in the eye, 192. 
Acetabulum, migration of, 791. 
Addison's disease, 704. 

differentiated from jaun- 
dice, 559. 
\denitis, tubercular, 384. 
Adenoids, 273. 
Adhesions, broken up after sprains. 



Adjustment, osteopathic, 90 



703 



Adrenal glands, diseases of. 
Aged, spine of the, 101. 
Agitans, paralysis, 723. 
Agitata, melancholia, 297. 
Ague, 347. 

Alcohol in postoperative pneu- 
monia, 319. 
Amentia, 290, 307. 
Amyloid kidney, 626. 

liver, 562. 
Amyotrophic lateral sclerosis, 762. 
Angina pectoris, 666. 

differential diagnosis, 667. 

pathology in, 308. 
Anemias, the, 672. 
Anemia, costogenic, 673. 

Burns, 673. 

pernicious, 678. 
•Aneurism, cardiac, 660. 
Animal experiments, 91, 490. 

parasites, 151. 
Ankle, 56. 

sprain, 112. 
-Ankylostoiasi-s, 155. 
.Anterior dorsal lesions technic, 76. 
.Vntid'ites may be necessary, 02. 
Antiseptics may be necessary, 62. 
,\ortic regurgitation, ()49. 

stenosis, 551. 
Aphonia, 571. 
Aphtho\is stomatitis, 488. 
Appendectomy, colitis follow- 
ing, 552. 
Appendicitis, .547. 

differential diagnosis, 550. 
Appendicitis from ileocecal troub- 
le, 141. 

pseudo, 550. 



Appendix innervation, 498. 
Arch supporters, 114. 
Arhythmia, 665. 
Arm affected by rib lesions, 740. 
Arm examination, 56. 

technic, 80. 

vasomotor nerves to, 94. 
Arteries, diseases of, 669. 
Arteriosclerosis, 669. 
Artery complications Irom ty- 

hpoid, 332. 
Arthritis deformans, 462. 

rheumatoid, 462. 

differentiated from inflamma- 
tory rheumatism, 459. 

septic, differentiated from in- 
flammatory rheumatism, 459 
Articular rheumatism, acute, 460. 
Asceris lumbriocoides, 153. 
Aspiration pneumonia, 605. 
Asthenopia, 232. 
Asthma bronchial, 589. 

caused by rib lesions, 94. 
Ataxia, Friedreich's, 759. 

hereditary, 759. 

differentiate chorea, 726. 

locomotor, 754. 
Ataxic paraplegia, 761. 
Atheroma, 669. 

in heart, 647. 
Atlas examination, 44. 

lesions, 44. 
Atrophy of optic nerve, 231. 

progressive muscular, 762, 764. 
Auditory — See also ear. 
Auditory meatus, diseases of, 236. 

nerve degeneration, 256. 

nerve lesions affecting, 718. 
Auerbach's plexus, 494. 
Autointoxication in nose diseas- 
es, 268. 
Axis lesions, 45. 

— B— 
Backache, postoperative, 313. 
Bandage, abdominal, for float- 
ing kidney, 137. 
liver, 139. 

sprain, 106. 
Barbadoes leg, 158. 
Baths, hot, in skin diseases, 147. 
Bee .sting near eye, 199. 
Bell's paralysis, 717. 
Belt — See bandage; also brace. 
Biceps, long tendon dislocated, 114. 
Bile duct, diseases of the liver 

and 553. 
Biliary colic, 565. 

differentiate, 551, 565,632. 
Binocular vision of osteopath (two 

pathologies), 489. 
Bin!) injuries, causes of heart ir- 
regularities, 606. 
Black eye, 199. 
Blackwater fever, 351 . 



Bladder, diseases of, 635. 

hemorrhage, 164. 

sensory nerves to, 95. 
Bleeders disease, 484. 
Blennorrhea, acute, 209. 
Blepharitis, 200. 

Blood flow directed to abdo- 
men, 582. 
Blood, diseases of, 671. 
Bones and joints, tuberculous dis- 
ease, 788. 
Bothriocephalus latus, 151. 
Bowel — See intestine. 
Brace in Pott's disease, 103, 131. 

in prolapse, 133. 

in spinal curvature, 99, 103, 122. 
Brachial neuralgia, 711. 

neuritis, 123. 

differential diagnosis, 125. 

plexus, lesions affecting, 721. 
Brachycardia, 664. 
Brain, pathology of, 307. 

its relation to mind, 307. 

physiology of, 306. 

tumors, differentiate mi- 
graine, 737. 
Brand bath, 329, 343. 
Breakbone fever, 356. 
Bright's disease, 618. 
Bronchi, dis-ases of the, 579. 
Bronchial asthma, 589. 
Bronchiolectasis, 587. 
Bronchitis, 579. 
Bronchopneumonia, 605. 

caused by tubercle bacillus, 606. 
Bronchopulmonary hemorrhage, 

160 
Bulbar paralj'sis, 765. 
Bunions, cause of, 112. 
Bursitis, 123. 

differentiate from neuritis, 125. 

Calcification in heart, 647. 
Calculus, renal, 631. 
Cancer of liver, 562. 

of stomach, differential diag- 
nosis, 508. 
Canker, 488. 
Carcinoma, location of reflex pain 

in, 499. 
Cardiac — See heart. 
Caries — See Pott's disease. 
Catalonia, 286. 
Cataract, 229. 
Catarrh 

dry, 583. 

of conjunctiva, vernal, 216. 
stomach, chronic, 505. 
Catarrhal deafness, 246. 

pneumonia, 605. 

stomatitis, 487. 
Center, diabetic, 474. 
Centers, osteopathic, 88. 

nutritional, 480. 



800 



The Practice of Osteopathy 



Cephalodynia, 465, 467. 
Cerebrospinal fluid interfered with, 
affects digestion, 492. 
meningitis, 358. 
Cerumen, inspissated, 236. 
Cervical — See also neck, 
examination, 41. 
glands, examination of, 47 
lesions affect eye, 93, 86. 
region, caution in treating, 66, 
treatment for vasomotor effects, 
92. 
Cervico-occipital and cervico- 

brachial neuralgia, 711. 
Chalazion, 200. 

Character and disposition affected 
by alimentary disturb- 

ances, 502. 
Chest examination, 51. 
Chiasm, diseases of, 715. 
Chicken-pox, 446. 

difffferentiate from smallpox, 417. 
Childbirth resulting in pendulous 

abdomen, 128 
Children — See also infants, 
defective, 303. 
diarrhea of, 529. 
Chlorosis, 676. 
Cholecystitis, 557. 
Cholera infantum, 531. 

morbus, 532. 
Chorea, 725. 

differential diagnosis, 726. 
differentiate paralysis agitans, 
724. 
Choreiform affections, 727. 
Choroid, diseases of, 226. 
Choroiditis, 226. 
Chromaffin system, 702, 703. 
Chronic lesions, reduce gradually, 

66. 
Chvostek's phenomenon, 701. 
Chyluria, chylocele, chylous as- 
citis, 158. 
Ciliary injection in keratitis, 221. 

body, diseases of the, 225. 
Ciliospinal center, 187. 
Circulatory system, disease of, 638. 
Circumflex nerve, lesions affect- 
ing, 721. 
Cirrhosis of liver, 560. 
Clavicle examination, 49. 
"Claw hand "764. 
Club foot, 784. 
Coccygodynia, 713. 
Coccyx examination, 55, 81. 
fractured, 81. 
technic,81,713. 
"Cold in the head," 257. 
Cold in treating sprain, 106. 
"Colds" inadvertently cured, 90. 
Cole's irrigator for high enema, 170, 

546. 
Colic, biliary, 565. 



differentiation of, 535, 566. 
intestinal, 535. 
renal, 631. 

differential diagnosis, 632. 
Colitis following appendectomy, 

552. 
Colitis, mucous, 526. 
Coma, diabetic, 472. 
Confusion and stupor, delirium, 289 
Congestion of the lungs, 610. 

thyroid, 686. 
Conjunctiva, diseases of, 202. 
Conjunctivitis, 202. 
catarrhal, 204. 

corneal ulcers complicating, 204. 
follicular, 207. 

differentiated from trachoma, 
208. 
gonorrheal, 209. 
granular, 212. 
phlyctenular, 214. 
vernal, 216. 
Constipation, causes and technic, 
497, 537 
from pendulous abdomen, 127. 
resulting in diarrhea, 538 
Constitutional diseases, 457. 
Contracted muscles relieved by 

inhibition, 89. 
Convulsions, infantile, 728. 
Cornea, anatomy of, 217. 
diseases of, 217, 219. 
examination of, 219. 
ulcerof,219,221. 
Coughing, 573. 
Coughing (superior laryngeal nerve) 

719. 
Cow-pox, 424. 
Cramp, constitutional, 738. 
Cranial nerves, diseases of, 715. 
Cretinism, 698. 
Croup treatment, 68. 

differentiate from spasm of glot- 
tis, 573. 
false, 574. 
Croupous pneumonia, 597. 
Curschmann's spirals, 586. 
Curvatures, spinal, 96, 99, 103, 
122, 768. 
See Abbott treatment, 
braces for, 99, 131. 
cervico-dorsal, 772. 
complicated by innominate 

lesion, 99. 
differentiate organic and func- 
tional, 769. 
dorsal, 772 
dorso-lumbar, 772. 
Cophosis, 97 

lateral, 98, 177. 
lumbar 772. 

other organs affected, 770. 
pathological, 96. 
rotary lateral, 768. 



postural, 128. 
(scoliosis) 96, 768. 
differentiated from Pott's dis- 
ease, 773. 
false, 773. 
structural, 774. 

technic for, 98. 
treatment for rotation and side- 
bending, 76. 
Cystitis, 635. 

Cystitis, differentiate pyelitis, 628, 
636. 



Dalrymple's sign, 694. 
Deafness, catarrhal, 246. 

nerve, 255, 718. 
Defective children, 303. 
Deformans, spondylitis, 463. 
Degeneration of heart muscle, 661. 
Deglutition, 493. 
Deglutition pneumonia, 605. 
Delirium, confusion and stupor, 
289. 
senile, 300. 
Dementia, arteriosclerotic, 300. 
defined, 306, 307. 
praecox, 287. 
senile, 297. 
Dengue, 356. 

Dental troubles should be cor- 
rected, 490. 
Descemetitis, 226. 
DeSchweinitz, Dr., 215. 
Diabetes, differential diagnosis, 477. 
insipidus, 476. 
mellitus, 470. 
Diabetic coma, 472. 
Diagnosis, osteopathic, 38. 
see also under lesion, 
reliable, osteopathic, 21. 
sight, 38. 
Diaphragm, paralysis of, 720. 
Diarrhea, causes and technic, 497. 
acute, 523. 

dyspeptic, 529 
caused by constipation, 538, 
of children, 529. 
chronic, 52. 

catarrhal, 524. 
differential diagnosis of, 530, 533 
nervous, 524. 

through impactions, 538, 544. 
Diet and osteopathy, 22, 62. 
Diet, diabetic, 475. 
Dietl's crisis, 137, 635. 
Digestion, relation of lungs to, 494. 
Digestive disturbances affect char- 
acter, 502. 
system, diseases of, 487. 
trouble due to intracranial con- 
ditions, 492. 
Digital surgery in hay fever, 226. 
treatment in tonsillitis, 281. 



The Practice of Osteopathy 



801 



Dilatation of heart, 657. 
of sigmoid, 543. 
of stomach, 153, 517. 
Diopter defined, 192. 
Diphtheria, 362. 

differentiated from scarlet fever, 

431. 
laryngeal, 364. 
nasal, 364. 

neuritis following, 707. 
pharyngeal, 364. 
Disease should be studied by 
regions, 586. 
constitutional, 457. 
general and functional, 723. 
Dislocation, differentiated from 

neuritis, 125. 
Disposition and character affected 
by digestive disturbances, 
501. 
Diuresis, Paroxysmal, differentiated 
from diabetes insipidus, 477. 
Dorsal spine examination, 49. 

technic, 74. 
Dorsodynia, 466, 467. 
Drugs not useful in nose and throat 
work, 262. 
Why medics give, 21. 
Dubini's disease, 727. 
Duodenal ulcer, Gastric and, 512. 
Duodenitis, 524. 
Dupuytren's contraction, 115. 
Dysentery, 368. 

Dysentry, A word on treatment 170 
amebic, 370. 
bacillary, 368. 
chronic, 371. 

treatment, a word on 170. 
tropical, 370. 
Dysmenorrhea caused by lumbar 

curvature, 126. 
Dyspepsia, acute, 501 . 
Dystrichiasis, 201. 

— E— 

Ear — See also auditory 
Ear, Diseases of, 236. 
of inner, 254 
of middle, 239. 
foreign bodies in, cause cough, 

575. 
normal hearing, 249. 
nose and throat, diseases of, 236. 
pain in diagnosis of diseases of, 

238. 
test for hearing, 249. 
vasomotor nerves to, 92. 
wax, hardened, 236. 
Ecchymosis, 109. 
Eclampsia, 728. 
Ectropion, 201. 
Eczema, 147. 
in ear, 230. 
Edema of the lungs, 611. 



Edwards finger treatment in hay 
fever, 267. 

trachoma treatment, 213. 

turbinate adjuster, 197. 
Egophony, Laennec's, 613. 
Elbow, 56. 

sprains, 114. 
Elephantiasis, 158. 
Emboli in endocarditis, 642, 644. 
Emphj'sema, 592. 

compensatory, 609. 

differential diagnosis, 595. 
Endocarditis, 641. 

complicating pneumonia, 601. 
Enema, directions for, 546. 
Enteric fever, 329. 
Enterocolitis, acute, -532. 
Enteroptosis, 521. 
Entropion, 201. 
Enuresis, 637. 

Epididemis sensory nerves to, 95. 
Epilepsy, 729. 

differential diagnosis, 734. 

nocturnal, 733, 734. 

grand mal, 732. 

Jacksonian, 733. 

petit mal, 733. 
Epilepticus, status, 734. 
Epistaxis, 160,271. 

differential diagnosis of, 161. 
Erb's phenomenon, 701. 
Erysipelas, 372. 
Esophagus, 493. 

location of reflex pain from, 499. 
Estivo-autumnal fever, 350. 
Etiological factors, 25. 
Etiology, osteopathic, 25. 
Examination — See under various 
structures and regions. 

thorough, essential, 38. 
Exercise and postural defects 120, 
129,131. 

cannot take place of osteopathy, 
120. 

in treatment of ptosis, 521. 
of false scoliosis, 773. 

to reduce abdomen, 128, 139, 

External cutaneous nerve, lesions 

affecting, 722. 
Eye, accommodation in the, 192. 
affected Ijy osseous lesions, 93, 
185, and under individual 
diseases. 
Eye diseases, 183, 713. 
Eye diseases, osteopathic manipu- 
lation in 190, 223, 710. 
examination by special methods, 

191. 
how to examine, 183. 
lesions affecting certain nerves 
of, 710. 
osteopathic, 184. 
neuralgia, 197. 



restored by osteopathy, A case 

history, 185. 
schematic, 194. 
strain and its reflexes, 231. 
trouble, nose and throat in, 191. 
vasomotor nerves, 92. 
Eyelids, diseases of, 199. 



Face examination, 46. 

technic, 68. 
Facial nerve, lesions affecting, 117. 
Fatty degeneration of heart, 661. 

liver, 561. 
Fecal impactions palpated, 52, 543. 

with diarrhea, 538, 544. 
Feet, neuralgia of, 714. 
Fetor oris, 491. 
Fever, 325. 

acute eruptive, mumps and 
whooping cough, 411. 

enteric 329. 

estivo-autumnal, 350. 

malarial, 347. 

paratyphoid, 344. 

remittent, 350. 

rheumatic, 457. 

simple continued, 379. 

treatment, 325. 

Brand method, 329. 
usually beneficial, 327. 

tj^phoid, 329. 

typhus, 344. 

yellow, 374. 
Fibroid phthysis, 393. 

induration, 609. 
Fifth nerve, neuralgia of, 710. 
Filaria, 158. 
Fingers, sprains of, 114. 

surgery in hay fever, 266. 

treatment in catarrhal deafness, 

in tonsillitis, 281. 
trigger, 115. 
First rib — see rib. 
Fissures of rectum, 174. 
Fistulae, rectal, 174. 
Flatfoot, 112, 787. 
Flatulency, technic for, 505, 537. 
Focus of infection — see infection. 
Foot, club, 784 

neuralgias, some causes of, 112. 
sprains of, 112. 
Fractures, 115. 
and sprains, 104. 

summary of massage and im- 
mobilization in, 118. 
of treatment of, 119. 
Frequency of treatments — see 

treatments. 
Friedreich's ataxia — See ;itMxia. 
Functional and general disoaKcs, 

723. 
Furunculosis of ear, 238. 



802 



The Practice of Osteopathy 



Gall bladder, sensory nerves to, 9.3. 
Gall stones, .563. 

easily diagnosed by osteopath, 
52. 
Ganglion (weeping sinew), 115. 
Gas in stomach, technic for, 505, 

537. 
Gastritis, acute, 502. 
chronic, 505. 

due to poital disturbance, 506. 
gastric analysis essential to diag- 
nose, 507. 
Gastric — see also indigestion. 
Gastric derangement, location of 
reflex pain from, 499. 
and duodenal ulcer, 513. 
neuralgia, 510. 
neuroses, 510. 
trouble often reflex, 510. 
General treatment — see treatment. 
Generative organs, vasomotor 

nerves to, 94. 
Genitocrural nerve, lesions affect- 
ing, 722. 
Genifo-urinary system, 175. 
Germ theorj' — its relation to oste- 
opathy. 26. 
German measles, 444. 

differentiate measles and scar- 
let fever, 446. 
Glands enlarged, differentiate from 
whooping cough, 454. 
examination of thyroid and cer- 
vical, 47. 
Glaucoma, 227. 
Glenard's disease, 521. 
Glosso-pharyngeal nerve, lesions 

affecting, 718. 
Glottis, spasm of, 572. 
Goiter, do not treat direct, 691, 696. 
exophthalmic, 690. 
findings at Mayo clinic, 692. 
parathyroid glands in 699. 
simple, 687. 
Gonorrhea germs in prostate, 176. 
Gonorrheal conjunctiv-itis, 209. 

rheumatism, 459. 
Gout, 467. 

differentiated from rheumatic 
fever, 459. 
Grand mal, 730, 732. 
Grattage, 213. 
Great occipital nerve, point of 

control, 719. 
Great auricular nerve, point of 

control, 719. 
Greensickness, 670. 

— H— 

Habit spasm, 728. 
Hammer toe, 112. 
Hand, sprain of, 114. 



Hay fever, 263. 

relation of focal infection to, 

266. 
treatment, 68. 
Head examination, 41. 

technic, 64. 

vasomotor nerves to, 92. 
Headache, from eye strain, 188. 

postoperative, 313. 

sick, 736. 

technic, 720. 
Hearing — see also ear. 

test, 249. 
Heart affected by stomach press- 
ure, 498. 

aneurism, 660. 

changes in goiter, G93. 

complications in typhoid, 332. 

crowded by round shoulders, 121. 

contraction mechanism, 665. 

dilatation, 657. 

diseases, 638. 
due to ribs, 47. 
causing hyperemia of liver, 554. 

enlargement causing cough, 575. 

failure in pneumonia, 603. 

hypertrophy, 655. 

hypertrophy and dilatation often 
recover, 654. 

irregularities due to birth in- 
jury, 666. 

muscle degeneration, 661. 

neuroses of, 662. 

palpitation of, 662. 

sen.sory nerves to, 95. 

stimulated through rectum, 169, 
170. 

trouble' and osteopathy, 647, 
648, 6.52. 
Heat in treating ear, 238, 240, 241. 

in treating sprain, 106. 

prostration, 181. 

stroke, 180. 
Hebephrenia, 286. 
Hematemesis, 162. 

differential diagnosis of, 161. 
Hematuria, 163. 
Hemophilia, 484. 
Hemoptysis, 160. 

differential diagnosis of, 161. 
Hemorrhages, 160. 

in feces, 163, 174. 

of intestines, 163, 174. 

of lungs, 160. 

of nose, 160. 

of stomach, 162, 516. 

of urinary tract, 163. 

of uterus, 164. 
Hemorrhoids, 171. 

acute, 173. 

due to portal obstruction, 560. 

treatment briefly discussed, 170. 
Hemmorrhagia subdermalis, 199. 
Hepatic colic. See biliary colic. 



flexure, prolapse, 140. 
Heredity, See Inherited. 
Hernia, 141. 

treatment, 546. 
Herpes, 149. 

conjunctivae, 214. 
zoster, 712. 

zoster ophthalmia, 199. 
Hiccoughs, 165. 
Hip, 56. 

congenital dislocation, 778. 

Lorenz operation, 781. 

open operation, 784. 

lesion affecting knee, 112. 

the prominent, description and 

treatment, 125. 
sprains of. 111. 
treatment following intracapu- 

lar fracture. 111. 
tuberculosis of, 791. 
Hip-joint disease, 791. 

treatment following. 111. 
Hives, 149. 
Hobnailed liver, 559. 
Hodgkin's disease, 684. 

differentiate from mumps, 451. 
Holmes electric auroscope, 236. 
Homatropine, 194. 
Hookworm disease, 155. 
Hordoleum, 200. 

Hospital — See postoperative treat- 
ment. 
Hot fomentations to relieve and 

relax, 95. 
Hydrophobia differentiated from 

tetanus, 378. 
Hydrotherapy in fever, 327. 
bronchial asthma, 589. 
often necessary with osteopathy, 
62. 
Hygiene necessary with osteop- 
athy, 62. 
Hyoid examination, 47. 

lesion affecting sense of taste, 491 . 
causing cough, 46, 574. 
furred tongue, 491. 
in bronchial asthma, .589. 
in lan.ngisimus stridulus, 572. 
in laryngistis 571. 
Hyperemia renal, 617. 
Hypertrophy of heart, 655. 
Hj-poglossal nerve, lesions affect- 
ing, 719. 
Hypopion in keratitis, 221. 
Hysteria, 740. 

Hysterical convulsions, differentiat- 
ed from epilepsy, 734. 
spine, 101. 
Hysterogenous zones, 743. 



-I— 



Icterus, 557. 
Idiots, 305. 
Ileocolitis, acute, ; 



The Practice of Osteopathy 



803 



Ileus, 540. 

Iliohypogastric and ilioinguinal 
nerves, lesions affecting, 722 
Imbeciles, 305. 

Immobilization in relation to 
tuberculosis, 115. 
See also under sprains. 
Impacted lesions, 92. 
Impactions, fecal, palpated, 52. 
of intestines, 543. 
of small intestine, 546. 
Impotency, 177. 
Indigestion — see also gastric, 
and asthma, 590. 

caused by' pendulous abdomen 
127. 
by round shoulders, 121. 
nervous, 521. 
Infantile convulsions, 728. 

paralysis — see poliomyelitis. 
Infants — see children. 

constipation treatment, 539. 
Infection differentiated from neu- 
ritis, 125. 
foci of, look out for, 131 
Infectious diseases, 325. 
Inflammatory rheumatism, 457. 
Influenza, Spanish or epidemic, 399. 

causes bronchitis, 79. 
Inherited tendencies in defective 

chUdren, 303. 
Inhibition, Osteopathic, 89, 94. 
Insanity, See also Mental diseases, 
acute confusional, 290. 
Circular, 293. 
defined, 306. 

(Physiology of brain) 305. 
Innominate examination, 52, 54. 
lesions preventing knee recovery, 

112. 
sprains. 111. 
technic, 79. 
dangerous, 87. 
Insect bites and stings, 199. 
Insipidus, diabetes, 476. 
Interrenal system, 704. 
Intestinal colic, 535. 
diseases, 523. 

relation of spinal lesions to 
gastro-, 489. 
obstruction, 541. 

differential diagnosis, .545. 
strangulation, 541. 
Intestine, examination of, 52. 
foreign substances in .542. 
impactions of 52, .543. 
treatment, 545, 546. 
with diarrhea, 538, 544. 
knots of, .542. 

treatment, 541, 545. 
location of reflex pain from, 499. 
obstruction of, 52, 78, 545, 546. 
differentiate from appendicitis, 
551. 



prolapsed, 52, 139. 
sensory nerves to, 95. 
strictures of, 543. 

treatment of, 545. 
technic, 78. 
tumors of, .543. 

treatment 545, 
twists, 542. 

treatment, 545. 
vasomotor nerves to, 94. 
Intranasal surgery, 266. 
Introduction, 17. 
Intercostal neuralgia, 712, 721. 
Intussusception, 541. 
Invagination, .541. 
treatment, .545. 
Iridocyclitis in keratitis, 221. 
Iris, diseases of, 225. 
Iritis complicating conjunctivitis, 
204. 
in keratitis, 221. 
Iron not indicated in anemic con- 
ditions, 623. 
— J— 
Jaundice, 5.58. 

differentiate from Addison's dis- 
ease, 559. 
simple catarrhal, 555. 
Jacksonian epilepsy, 730, 733. 
Jaw, full motion essential, 490. 
lesions, 46, 491. 
technic, 68. 
Joints and bones, tuberculosis of, 
788. 
function is motion, 489. 



Keratoconus, 218. 
Keratitis, 219. 

cornea-phlyctenular, 214. 

neuroparalytica, 223. 

parenchymatous or interstitial, 
224. 
Keratitis, phlyctenular, 224. 
Keratomalacia, 219, 223. 
Kidney, amyloid, 620. 

complications in typhoid 331. 

diseases of, 617. 

cxamiaation, 52 

hemorrhage, 164. 

movable, 634. 

prolapsed, 136. 
belt for, 137. 

sensory nerves to, 95. 

stones, 63 1. 

treatment, 78, 620, 623. 

vasomotor nerves to, 94. 
Knee, tuberculosis of, 793. 
Kraepelin's classification of d 

mentia praeeox, 283. 
Kyphosis — See curvatures. 

— L— 
Labiogloasopharyngeal l)llru1.\•si^ 
765. 



Laboratory experiments on ani- 
mals (Lesions), 91. 
Labyrinthitis, 2.54. 
Lachrymal apparatus, Diseases of, 

202. 
Laennac's egophony, 613. 

pearls, 586. 
Landmarks of spine, 39. 
I^andry's disease differentiated from 
myelitis, 749. 
paralysis, 753. 
Laryngeal nerve technic, 719. 

lesions affecting superior and 
inferior, 719. 
I^aryngismus stridulus, 572. 

differentiated from croup, 573. 
Laryngitis, acute catarrhal, 569. 
chronic catarrhal, 570. 
edematous, 577. 
spasmodic, 573. 
.syphilitic, 577. 
tuberculous, 575. 
Larynx complications in typhoid, 
332. 
diseases of, 569. 
examination, 47. 
technic, 67. 
Lateral curvature, 98. 
Lead colic differentiated from in- 
testinal colic, 535. 
poisoning, Neuritis from, 707. 
Leg examination, 56. 
neuralgia of, 714. 
technic, 80. 

vasomotor nerves to, 91 
Lens, diseases of, 229. 

opacity, 229. 
Lenses explained, 191. 
Leprosy, anesthetic, differentiated 
from syringomyelitis, 762. 
Lesions of each part or organ 
indexed under respective 
names of parts, but not un- 
der all diseases in which they 
may be found 
I,psion affecting one visc\is affects 
others also, 494. 
caused by visceral disturbance, 

.501,503. 
chronic, reduce gradually, 06. 
composite, 30. 

dominant in causing gastro-in- 
testinal disease. Osteopath- 
ic, 489. 490. 
effects of, 33. 
effects in heart cases, Osteo 

pathic, 647, 048. 
impacted, 92. 

i.-i ab.sence of motion, 489. 
ligamentous, 28. 
mascular, 27, 41, 45. 

caused by visceral disturbances 

500. 
of various structures and re- 



804 



The Peactice of Osteopathy 



gions, ponsidcred in con- 
nection with osseous lesions 
of same, 
osseous, 20. 

also listed under various bones, 
organs and regions, 
pathognomonic sigrts of, 30. 
results stated by ISIcConneli, 490 
to diagnose, 38, 39, 91. 
visceral, 29. 
Leyden's crystals, 586. 
Leukemia, 680. 

acute myelogenous, 681. 
lymphatic, 682. 
splenomedullary, 081' 
Lithemia, 469. 
Liver, amyloid, 562. 

and bile duct, di.seases of, 553. 
cancer of, 562. 
(cholecystitis), 557. 
cirrhosis of, 560. 
complications in typhoid, 332. 
examination, 51. 
fatty, 562. 
(gallstones), 564. 
hyperemia of, 554. 
inactivity from pendulous ab- 
domen, 127. 
innervation, 474. 
involved in rheumatism, 460. 
(jaundice), 558. 

location of reflex pain from, 499. 
nutmeg, 553. 

pain reflex to scapula, 721. 
(simple catarrhal jaundice), 555. 
prolapse, 138. 
sensory nerves to, 95. 
technic, 77. 

vasomotor nerves to, 94. 
Lobar pneumonia, acute, 597. 
Lock-jaw, 377. 
Ijocomotor ataxia, 754. 

differentiated from Fried- 
reich's ataxia, 759. 
Lordosis, 97. 
Lorenz operation, 781. 
Lumbago, 465, 46G. 
Lumbar curve and prolapsed uter- 
us, 143. 

prominent hip, 125. 
examination, 49, r>2. 
lumbar nerves, lesions affecting, 

722. 
technic, 74. 
Lumbo-abdominal neuralgia, 713. 
Lungs affected by stomach p.-ess- 
ure, 498. 
complications in typhoid, 332 
congestion, 610. 

crowded by round slioulder.s, 121. 
diseases, 592. 
due to ribs, 47. 

causing hyperemia of liver, 554 
edema of 611. 



relation to digestion, 494. 

sensory nerves to, 95. 

stimulated through rectum, 169, 
170. 

vasomotor nerves to 93, 
Lymphatic leukemia, 682. 
Lymphadenoma, 684. 

— M— 

McBurney's point, 549. 

why pain in appendicitis, 499. 
Macula lutea, 195. 
Maddoxrod, 193. 
Mai, grand, 730, 732. 

petit, 730, 733. 
Malaria associated with typhoid 

.337. 
^L^larial cachexia, 351. 

fever, 347. 

pernicious, 350. 

hematuria, 351. 
Mammary gland innervation, 722. 
Manic depressive psychoses, 291. 
Massage following hip joint dis- 
ease. 111. 
intracapsular fracture of hip, 
111. 

of fractures, 116. 

of sprains, 109. 

not osteopathy, 19. 
Mastoiditis, 240. 

Mayo clinic's goiter findings, 692. 
Measles, 437. 

a cause of bronchitis, 579. 

differentiate German measles, 
446. 
scarlet fever, 432. 

German, 444. 
Meatus of ear, atrophic, 237. 

infection of, 238. 
Medulla contains vasomotor center, 

92. 
Meibomian cyst, 200. 
Meissner's plex.us, 494. 
Melancholia agitata, 297. 
Mellitus, Diabetes, 470. 
Meniere's disease, 254, 718. 

symptom complex, 253. 
Meningeal tuberculosis, 387. 
Meningitis, cerebrospinal, 358. 

complicating pneumonia, 601. 

tubercular, 360. 
Menopause, thyroid enlargement 

during, 686. 
Mental deficiency, 305. 

diseases, 282. 

osteopathic lesions in, 289. 
Microcephalus, 308. 
Migraine, 736. 
Milk leg, 167. 

Mind, relation to brain, 307. 
Miner's anemia, 155. 
Mitral regurgitation, 648. 

stenosis, 649. 



Moebius' sign, 694. 
MorbilU, 437. 
Mongohan amentia, 309. 
Morons, 305. 
Morphine habit, phyr 

sieians respon.sible, 715. 
Morton's disease, 112. 
Morvan's disease, 762. 
Mosquito carrier of filaria, 158. 
Motion is function of joint, 489. 
Motor oeuli nerve, lesions affect- 
ing, 716. 
Mouth, diseases of, 487. 
Mucous colitis, 520. 
Mumps, 449. 

whooping cough and acute 
eruptive fevers, 410. 
differential diagnosis, 451. 
Murmurs, Heart, 042, 643. 
Muscle contractions caused by vis- 
ceral disturbances, how, 500. 
relieved by inhibition, 89. 
Muscular lesions, 27, 41, 45. Also 
considered in connection 
with osseous lesions of var- 
ious parts, 
rheumatism, 465. 
Musculacutaneous nerve, lesions 

affecting, and results, 721. 
Myalgia, 467. 
Mydriatic, 194. 
Myelemia, 681. 
Myelitis, 707. 
acute, 748. 
chronic, 750. 
diffuse, 749. 
transverse, 748. 
Myelogenous leukemia, acute, 681 
Myeloid leukemia, 681. 
Myocarditis, 659. 
Myoclonia, 727. * 

:Myxedema, 097. 

— N— 
Nasal — See nose 
Nasopharyngitis, 272. 
Na.sopharynx, diseases of, 272. 
Neck — See also cervical. 
Neck examination, 47. 
muscle lesions, 46. 
stiff, 465, 466. 
technic, 64, 66. 

dangers of, 66, 86. 
Nephritis differentiated from pye- 
litis, 628. 
hemorrhagic, chronic, 622. 
interstitial, 624. 

differentiated from diabetes 
in.sipidus,477. 
parenchymatous, acute, 61S. 

chronic, 621. 
postoperative, 314. 
Nerve centers (osteopathic) 88. 
deafness, 255, 718. 
degeneration, auditory, 256. 



The Practice of Osteopathy 



805 



diseusesof, 706. 

ci-iinial, diseases of, 715. 

spinal, diseases of, 719. 

sensory, 94. • 

vasomotor, 92. 
Nervous indigestion, 511. 

prostration from prolapse, 12S. 

system, diseases of, 706. 
Neuralgia, 710. 

cervico-brachiai and brachial, 711 

cervico-occipital, 711. 

differential diagnosis, 714. 

intercostal, 721. 

of eye, 197. 

of fifth nerve, 710. 

of foot, some causes, 112. 

of legs and feet, 714. 

of sacral nerve from impacted 
feces, 537. 

of sacral region, 713. 

of spinal column, 713. 

of trunk, 712. 

relieved by inhibition, 89. 
Neuresthenia, 744. 
Neuritis, 706. 

brachial, 123. 

differentiated from neuralgia, 714 

multiple, differentiated from Lan- 
drjf's paralysis, 753. 

from myelitis, 749. 

optic, 230. 

postoperative, 313. 

retrobulbar, 231. 
Neuroses of heart,' 662. 

gastric, 510. 
Neurosis, occupation, 738. 
" Neurotic spine, " 101. 
Nocturnal epilep.sy, 733, 734. 
Nose and throat in eye troubles, 
191.196,225,229. 

antiseptic sprays etc., 2.58, 262. 

conditions in torticollis, 466. 

diseases of, 257. 

intranasal treatment, 260. 

packing, 267, 268. 

pharmacodynamics of, 262. 

syphilis of, 270. 

throat and ear, diseases, 230. 

nosebleed, 161,271. 

differential diagnosis, 161. 
Nursing necessary to osteopathy, 62 
Nutmeg liver, 554. 

-0-, 
Obesity, 480 

exercises to reduce abdomen, 
128,139,480. 
Obstetric cases, innominate Icosin 

in, 108. 
Obstruction, intestinal— see intes- 
tinal. 
(Jbturator nerv-e, lesions affecting, 

722. 
Occipito-allantal (•x.'iminiitif)n and 
lesions, 45. 



technic, 67. 
Occupation neurosis, 738. 
Olfactory nerve, diseases of, 715. 
Omodynia, 466, 467. 
Ophthalmia neonatorum, 210. 

purulent, 209. 

sympathetic, 227. 
Ophthalmology, 183. 
Ophthalmoscope, 193. 
Optic disc, 195. 

nerve atrophy, 231. 

probably connection with 
third, 234. 

neuritis, 230. 

tract, diseases of, 715. 
Oropharynx, diseases of, 274. 
Orthopedic Surgery, 767. 
Osteopathic centers — see centers. 

diagnosis and prognosis, 38. 

etiology and pathology, 24. 

examination of eye 184. 

inhibition, 89. 

lesion defined, 24. 

manipulation in eye diseases, 
196, 213. 

readjustment, 90. 

stimulation, 88. 

theory, proof of, 34 

scientific demonstration, 89. 

treatment, general directions, 58. 
Osteopathy, definitions of, 18. 

includes many measures, 62. 

not massage, 19. 

not passive exercise, 129. 

not Swedish movements, 19,63,68 
Otitis media, acute suppurative, 239 

chronic suppurative, 243. 
differential diagnosis, 244. 

nonsuppurative, 246. 
Ovarian examination, 56. 
Ovary, prolapse of, 144. 

sensory nerves to, 95. 
Oxyuris vermicularis, 1.54. 



Pachymeningitis, cervical, differ- 
entiated from syringomye- 
lia, 762. 

Packing, nasal, 207, 268. 

Pains, location of reflex, 499. 

Palpation, educated, 60. 
practice in, 87. 

Palpitation, 662. 

Pannus, 224. 

Panophthalmitis, 227. 

Papillae in rectum, 174. 

Paralysis, acute ascending, 753. 

Paralysis agitans, 723. 

differential diagnosis, 724. 
bulbar, 765. 

Paralysis, infantile, 750. 

Paranephritic abscess differentiated 
from pyelitis, 628. 

Paranoia, 287. 



Paraplegia, ataxic, 761. 

spastic, 760. 
Parasites, animal, 151. 
Parathyroid glands^diseasesof, 699. 
Paratyphoid fever, 344. 
Paris, plaster of, 795. 
Parotiditis, epidemic, 449. 

differential diagnosis of, 451. 
Parotitis, epidemic, 449. 
Patheticus nerves, lesions affecting, 

716. 
Pathologies, osteopathy recognizes 

two distinct, 489. 
Pathology, osteopathic, 31. 
Patient's receptivity to treatment, 

61. 
Pearls, Laennec's, 591. 
Pelvic examination, 52. 

prolapse caused by abdominal 
prolapse, 128. 

technic, 78. 
Pendulous abdomen, 127. 
Pericarditis, 638. 

complicating pneumonia, 600. 
Pericardium, diseases of, 638. 
Peristalsis explained, 494. 

reversed, normal in parts of colon, 
497. 

technic to affect, 495. 
Peritonsillar abscess, 278. 
Pernicious anemia, 678. 
Pertussis, 452. 
Petit mal, 730, 733. 
Pharyngitis, 274. 

Pharynx complications in typhoid, 
332. 

technic, 67. 
Phenol-glycerine formula, 263. 
Phlebitis, 167. 

postoperative, 313. 
Phlegmasia alba dolens, 167. 
Phlyctenular keratitis, 224. 
Phrenic nerve, lesions affecting, 720. 
Phthisis, see tuberculosis 
Piles, 171. 
Pinworm, 154. 
Plaster of Paris, 795. 
Pleura, diseases of, 611. 
Pleurisy, 611. 

complicating pneumonia, 
600. 

differentiated from pneumonia, 
601. 

postoperative, 314. 
Pleurodynia, 465, 466, 712. 
Pneumogastric nerve, lesions af- 
fecting, 718. 
Pneumonia, acute lobar, 507. 

aspiration, 605. 

alcohol not indicated in, 319. 

associated with endocarditi.s, 044 

bronchial, 605. 

caused by tubercle bacillus, 606 

catarrhal, 605. 



806 



The Practice of Osteopathy 



complication of typhoid, 332 

chronic interstitial, 009. 

croupous, 597. 

tlifferential tliagnosis of, 009. 

deglutition, 605. 

differential diagnosis of, 001. 

postoperative, 314. 
Pneumonia, strychnine not indi- 
cated in, 320. 
Pneumonic phthisis, 388. 
Poliomj'elitis, 750. 

causing scoliosis, 770. 

difierentiated from myelitis, 749. 
Polj'uria,476. 

Portal system, vasomotors to, 94. 
Posterior spine technic, 101. 

thoracic nerve, lesions affecting, 
721. 
Postoperative treatment, 312. 
Postural curves of spine, 128. 

defects, 120. 
Posture, correct, 127, 128. 
Pott's disease, 102,788. 

differentiated from kyphosis, 
97. 

from scoliosis, 773. 
treatment, 102. 
Proctitis, 170. 

Prognosis and diagnosis, osteo- 
pathic, 38. 

osteopathic, 50. 
Progressive muscular atrophy, 764. 
differentiated from syringo- 
myelitis, 762. 
Prolapse — See also ptosis. 
Prolapsed hepatic flexure, 139. 

intestines, 139, 170. 

kidney, 136. 

liver, 138. 

organs, 127, 133, 521. 

ovaries, 144. 

rectum, 171. 

sigmoid flexure, 141, 170. 

stomach, 134. 

uterus, 143. 
Prominent hip, 12."). 
Prostate gland, 175 

technic, 637. 

sensory nerves to, 95. 
Prostatitis, 175. 
Prostatorrhea, 176. 
Pseudo-angina pectoris, 667. 

appendicitis, 550. 

croup, 572. 

leukemia, 684. 
Psychalgia, 293, 296. 
Psychosis, involutional, 295. 
Ptosis — See also prolapse. 

of abdominal organs, 127. 

of eyelids, 201. 
Pulmonary regurgitation, 650. 

stenosis, 650. 
Punctumproximum, 192. 

remotum, 192. 



Purpura, 483. 

variolosa, 420. 
Pyelitis, 627. 

differential diagnosis, 628, 636. 
Pyelonephritis, 027. 
Pyemia, 356. 

— o— 

Quinsy, 278. 

— R— 

Radial nerve, lesions affecting, 739. 
Rash, differentiate scarlet fever 

from drug >.r septic, 431. 
Receptaculum chyli, vasomotor 

nerves to, 94. 
Rectal conditions requiring sur- 
gery, 174. 

disorders, brief di.scussion, 141. 

examination, 55, 56, 169. 
Rectum, 169. 

to dilate, 170. 

technic, 169. 
Reflex gastric troubles, 509. 

pains, location of various, 499. 
Reflexes, somatic, Burns experi- 
ments, 189. 
Regions of body should form basis 
of disease classification, 586. 
Regurgitation, aortic, 649. 

mitral, 648. 

pulmonary, 650. 

tricuspid, 650. 
Remittent fever, 350. 

differentiate from yellow fever, 
375. 
Renal calculus, 631. 
Re,nal colic — see colic. 

differentiate fiom appendicitis 
551. 
Respiratory diseases 569' 

reflex inefficiency, 264. 
Retina, diseases of, 230, 715. 
Retinitis, 230. 
Retrobulbar neuritis, 231. 
Rheumatic fever, 457. 
Rheumatism, abdominal, 406, 467 

cause of heart valve defects, 645. 

chronic articular, 460. 

differential diagnosis, 459. 
and brachial neuritis, 125. 

gonorrheal, 459. 

inflammatory, 457. 

muscular, 465. 

subacute, 459. 
Rheumatoid arthritis, 462. 

differentiated from rheumatic 
fever, 459. 
Rhinitis, acute, 257. 

atrophic, 261. 

chronic hypertrophic, 2.39. 

hyperesthetic, 263. 

purulent, 259. 
Ribs, danger in elderly patient.", 87. 

examination, 47. 



false, technic, 74. 
first, examination, 49. 

technic, 72. 
floating, 49. 

technic, 73. 
lesions cause heart trouble, 648, 
653. 
described, 48. 
sprains. 111. 
technic, 69. 
Rickets, 478. 
Rose spots, .334. 
Round shoulders, 121, 130. 

worm, 151. 
Rubella, 441. 

differentiated from measles and 
scarlet fever, 446. 
Rubeola, 437. 

Ruddy nasal third finger, 197. 
third finger eye instrument, 214, 

229. 
treatment of tonsillitis, 281. 



.St. Vitus' dance, 725. 
Saccules in rectum, 174. 
.Sacial ner\^es, lesions affecting, 722. 
neuralgia, 713. 

caused by impacted feces, 538. 
Sacro-iliac — see innominate. 
Sacrum examination, 55. 

technic, 82. 
Salivary glands, 491. 
Sallow skin, 559. 
Scalp, 40. 

technic, 68. 
Scapula, technic, 08. 
Scapulodynia, 466, 467. 
Scarlatina, 428. 

differentiate diphtheria, 432. 
drug rash, 431. 
German measles, 432, 446. 
measles, 432. 
septic rash, 431. 
types and forms, 432. 
Scarlet fever — .see scarlatina. 
Schematic eye, 194. 
.Sciatica, 708, 714. 

"Scissors" technic dangerous, 86. 
Sclerosis, amyotrophic lateral, 762, 
763. 
differentiate from syringomye- 
lia, 762. 
cerebral, differentiate from cho- 
rea, 726. 
disseminated, differentiate from 
paralysis agitans, 724. 
Scoliosis — See curvatures. 
Scrofula, 384, 396. 
Scrofulous ophthalmia, 214. 
Scurvy, 481. 
Seminal vesicles, 176. 
Senile delirium, 300. 
dementia, 297. 



The Practice of Osteopathy 



807 



Sensory nerves to various viscera, 
94. See also under various 
viscera. 
Septic rash, differentiate scarlatina, 

431. 
Septicemia, 35.5. 

"Setting-up" exercises for pendu- 
lous abdomen, 128. 
Shaking palsy, 723. 
Shoulder, 56, SO. 
painful, 122. 
round, 121. 
sprain of, 114. 
Sight — see eye. 
diagnosis, 38. 
Sigmoid impaclion causing cough, 
575. 
prolapse, 141. 
Sinuitia, 269. 

vacuum, 270. 
Skin diseases, 147. 
Small occipital norve, point to con- 
trol, 719. 
Small-pox, 412. 
black, 420. 

differentiate from chicken-pox, 
.417. 
Smell, sense of, 491. 
Snellin's test type, 191. 
Solar plexus inhibition, .582. 
Somatic reflexes — -Burns experi- 
ments, 188. 
Spasm — see convulsions. 

habit, 728. 
Spastic paraplegia, 760. 
Sphincters, alimentary, 490. 

ani, external, 49S. 
Spina! accessory nerve, lesions af- 
fecting, 719. 
centers (osteopathic), 88. 
column, neiiralgia of, 713. 

postural curvatures of, 128. 
cord, diseases of, 748. 
curvature, pathological, 96. 

technic, 97. 
examination, importance of, 41. 
landmarks, 39. 
lesioas — see lesions, 
nerves, diseases of, 719. 
stretching, dangers of, 86. 
Spine the center of osteopathic 
interest, 38. 
hysterical, description and tccii- 

nic, 101. 
neurotic, description iind tecli- 

nic, 101. 
of the aged, description and tech- 
nic, 101. 
posterior, technic, 101. 
sprains of, 110. 
straight, 99. 

technic, 100. 
tubercular di.sease of, 788, 102. 



typhoid, description and technic, 
100. 
Splanchnic technic, 495. 
Spleen complications in typhoid, 
332. 

diseases of, 567. 

examination, 52. 

treatment, 78. 

vasomotor nerves to, 94. 
Splenitis, 567. 

Splenomedullary leukemia, 681. 
Spondylitis deformans, 463. 
Sprains and fractures, 104. 

bandaging not always good, 107. 

heat and cold in treatment, 106. 

immobilization and rest, 106, 115. 

massage, 109, 116. 

of ankle, 112. 

of elbow, 114. 

of fingers, 114. 

of foot, 112. , 

of hip, 111. 

of innominate. 111. 

of knee, 112. 

of ribs. 111. 

of shoulder, 114. 

of spinal column, 110. 

of wrist and hand, 1 14. 

passive movement, 107. 

summary of treatment, lib. 
Stand erect, how to, 127. 
Status epilepticus, 734. 

lymphaticus, 702. 
Stenosis, aortic, 650. 

mitral, 649. 

pulmonary, 050. 

tricuspid, 650. 
Sternum examination, 49. 

technic, 73. 
Still, early struggles of Dr. A. T., 17 
Still-Hildreth Sanitarium 280, 291. 
Several times in chapter on 
mental and nervous dis- 
eases. 
Stimulation, osteopathic, 88. 
Stomach, — sec also digestive sys- 
tem. 

cardiac relaxation by inhibition, 
89. 

conditions in bronchial asthma, 
,5S9. 

dilatation, 134. 

differentiate from gastroptosia, 
1.34. 

distention, 498. 

examination, 52. 

hemorrhage, 162, 516. 

pain over pit of, due to cutaneous 
.scn.sory nerves, 721. 

prolapse, 134. 

sen.sory nerves to, 95. 

technic, 78. 

ulcer, spinal causes of, 498. 



Stomatitis, 487. 
Stones, gall, 563. 

kidney, 631. 
"Straight spine, " 99, 130. 

technic for, 100. 
Strangulation of intestines, 541. 
Stretching, indiscriminate, 86. 
Strychnine not indicated in post- 
operative pneumonia, 320. 
poisoning differentiated from 
tetanus, 378. 
Stupor, delirium and confusion, 289. 
Sty, 200. 
Sunstroke, 180. 
Supports, arch, 114. 

in prolapse, 133, 142. 
Suprarenal capsule. Dr. Still's the- 
ory, 633. 
Surgery, relation to osteopathy, 22. 
in various conditions, taken up in 
connection with treatment, 
orthopedic, 767. 
Swallowing, 492. 

Swedish movements not oste- 
opathy, 19, 63, 68. 
Synechiae in keratitis, 221. 
Syphilis of nose, 270. 

of thyroid, 687. 
Syphilitic laryngitis, 577. 
Syringomjfelia,701. 

differential diagnosis, 762. 

— T— 

Tabes dorsalis, 754. 

Tachycardia, 663. 

Taenia fiavo-punctata, 151. 

saginata, 151. 

solium, 151. 
Talipes, 784. 
Tape worm, 151. 
Taste, bad, in mouth, 492. 

sense of, 491. 
Technic, see under osteopathic 
treatment; also under vari- 
ous regions, and organs. 

dangerous, 86. 

osteopathic, 60. 
Teeth conditions in torticollis, 466. 

defects should be corrected, 490. 
Tompero-mandibular — see jaw. 
Tenesmus treatment, 170. 
Testes, sensory nerves to 95. 
Tetanus, 377. 

differentiated from hydropho- 
bia, .378. 
strychnine poisoning, 378. 
Tetany, 699. 
Thorax examination, 51. 
Threadworm, 154. 
Throat and nose in eye trouble, 

191, 196, 225, 229. 
Throat, diseases of the ear, nose 
and, 230. 



808 



The Practice of Osteopathy 



(Edwards' turbinate adjustor) 
197. 

irritation due to hyoid, 47. 

(Ruddy's nasal third finger), 197. 

technic, 67. 
Thrombosis from typhoid, 332. 
Thrush, 488. 

Thyroid gland, direct manipula- 
tion dangerous, 696. 

diseases of, 686. 
Thymus gland enlarged in goiter, 
691, 693. 

diseases of, 702. 
Tic, convulsive, 728. 

douloureaux, 711. 

general, 728. 
Tongue, 490. 

furred, 491. 

vasomotor nerves to, 92. 
Tonsils. 67. 

function of, 276. 

in rheumatism, 457, 400. 

in torticollis, 466. 

palpated, 47. 

(peritonsillar abscess), 278. 

trouble in eye disease, 196. 
Tonsillectomy, 278. 

summary of indications for, 280. 
Tonsillitis, 276. 

technic, 68, 279, 280. 
Torticollis, 129, 465, 466, 719. 
Touch, educated sense of, 60. 
Trachoma, 208, 212. 

differentiated from follicular con- 
junctiv-itis, 20S. 
Traction, reasons for, 62. 
Transillumination in diagnosing 

sinuitis, 269. 
Treating (over-treating), 84. 

in influenza, 404. 
Treatment — see also technic. 

after a meal, 83. 

frequency of, 83, 84. 

general, 62, 68, 90. 

should be given when, 63. 

inhibition to begin, 89. 

length of, 84. 

misapplied, 85, 87. 

position of phy.sician and pa- 
tient, 63. 

receptivity of patient to, 61. 

resulting in some motion, leave 
lesion for that time, 76. 

to be avoided, 86. 

value of vacation from, 85. 
Tremors, differentiate from paraly- 
sis agitans, 724. 
Trichiniasis, 156. 
Trichiasis, 201. 
Tricuspid regurgitation, 650. 

stenosis, 650. 
Trigeminous nerve, lesions affect- 
ing, 717. 



Trigger-finger, 115. 
Trousseau's phenomenon, 701. 
Tubal disease, differentiated from 

appendicitis, 551. 
Tubercle bacillus may cause bron- 
chopneumonia, 606. 
Tuberculo.sis, 380. 

and joint immobilization, 115. 

of alimentary tract, 393. 

acute, 386. 

begins as chronic gastritis, 506. 

bones and joints, 788. 

bronchopneumonic, 388. 

cerebral, 387. 

deformities predisposing factors, 

389. 
differentiate from brachial neu- 
ritis, 125. 
pneumonia, 601. 
(fibroid phthisis), 393. 
differentiate from chronic in- 
terstitial pneumonia, 609. 
of genito-urinary tract, 394. 
of hip, 791. 
of knee, 793. 
of lymph glands, 384. 
of miliary, 386, 394. 
pneumonic, 386. 
pulmonary, 387, 389. 
of spine, 102, 788. 
orthopedic surgery necessary in, 

767. 
of thyroid, 687. 
Tuberculous laryngitis, 575. 
Tumor, brain, differentiate from 

migraine, 737. 
Tuning fork tests, 294. 
Turbinates, to clean around iu 

rhinitis, 260. 
Tussis convulsiva, 4.52. 
Typhoid fever, 329. 
afebrile, 334. 

fever associated with malaria, 337 
do not manipulate abdomen, 

163. 
differentiated from appendi- 
citis, 551. 
spine, 100. 
Typhus fever. 344. 

—XT- 
Ulcer of cornea, 219, 221. 
gastric and duodenal, 512. 
location of reflex pain in gastric 

or duodenal, 499. 
of stomach, spinal causes of, 498. 
differential diagnosis, 508, 515. 
Ulcerative stomatitis, 164. 
Ulnar nerve, lesions affecting, 726, 

739. 
Uncinariasis, 155. 
Uremia, 628.- 
Uremic convulsions, differentiated 



from epilepsy, 734. 
Ureter, sensory nerves to, 95. 

hemorrhage, 164. 
Urethra hemorrhage, 164. 
Urinary system, diseases of, 617. 
Urine, blood in, 163. 

massage prostate for retention of, 
176. 
Urticaria, 149. 
Uterine examination, 56. 

hemorrhage, 164. 
THerus, prolapsed, 143. 

sen.sory nerves to, 95. 



Vaccination, 424. 

Vaccinia, 424. 

Valve diseases, heart, 642, 644, 645, 

649,651. 
Varicella, 424, 446. 

differentiated from variola, 417. 
Varicocele, 176. 
Varicose veins, 166. 
Variola, 412. 

cornea, 421. 

differentiated from varicella, 417 

hemorrhagica pustulosa, 420. 

vera, 418. 

verucosa, 420. 
Varioloid, 420. 
Variolosa purpura, 420. 

sine exanthemate, 420. 
Vasomotor nerves, 92. 
Venereal disease and eye trouble, 

184. 
Vertebrae, landmarks for dis- 
tinguishing, 39. 
Vision explained, 230. 
Volvulus, 541. 

Vomiting, persistent, mostly re- 
flex, 501. 

postoperative, 312. 

technic to relieve, 504. 
von Graefe's sign, 694. 

— W— 

Water, drink plenty, 540. 
White swelling, 793. 
Whooping cough, 452. 
Whooping cough, mumps, and 
acute eruptive fevers, 411. 

differentiate enlarged glands, 454. 
Worms, intestinal, 151. 
Wrist, 56. 

sprain, 114. 
Wr\--neck — see torticollis. 

— \ — 

Yellow Fever, 374. 

differentiate from remittent fin- 
er, 375. 

— Z— 
Zuckerkandl's organ, 703. 































-^'"'\-o^\'^ 














./^ 



•^o V 



ax^ . 



*.'^. 



T^ 



0^ 



s * , ^ 

'i L 



-«--v,.^ 'c/. 










\' V 






0^ 



./' ^ 




.#'%, 



O •' , ,V -^ .A 



™^;..'; 

s:^;^-- 






>>. 



/." #*<%,. \ 







:', %> /,i|nS/-- ^".^ / 









^o V'- 
















• ' a 4 ^ 4^ 



•^^ ° / 



-0' 



\ 






,0 ^ - ^'''^- 



\0 







■^v. ^'^- 






=o V 






i^N^ V 





'^^. *,,^■'^ A^^ 



•„ ■ e>* *W„V^ '^ .^ 



■^^. '''' r^^ .>"■ o,'?-' 






A^ %. 



^^ '^r, 












.'.*#^2!%^^ -^ 









.-b- 



V' <^^ 



.S^ '^' 



'X\^^'%. 









"b V 



